Basic Information
| Provider Information | |||||||||
| NPI: | 1255518486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EICHELBAUM | ||||||||
| FirstName: | EHRENTRAUD | ||||||||
| MiddleName: | JOHANNA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1113 LATTIMORE DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347119032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417794869 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 212 S FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527932441 | ||||||||
| FaxNumber: | 3527933282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 238000185 | IL | N | 208D00000X | 18573 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ME140028 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.