Provider Demographics
NPI:1316966815
Name:EISENBERG, ELYSE RAE (MD)
Entity type:Individual
Prefix:DR
First Name:ELYSE
Middle Name:RAE
Last Name:EISENBERG
Suffix:
Gender:
Credentials:MD
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Mailing Address - Street 1:6114 LA SALLE AVE
Mailing Address - Street 2:438
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2802
Mailing Address - Country:US
Mailing Address - Phone:707-523-3375
Mailing Address - Fax:866-870-0815
Practice Address - Street 1:725 FARMERS LN
Practice Address - Street 2:STE 10
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6710
Practice Address - Country:US
Practice Address - Phone:707-523-3375
Practice Address - Fax:866-870-0815
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG64542207QA0401X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-8789321OtherFEDERAL EIN TAX ID