Basic Information
| Provider Information | |||||||||
| NPI: | 1316936164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EUSEBIO | ||||||||
| FirstName: | EMMANUEL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | PEACEHEALTH MEDICAL GROUP | ||||||||
| Address2: | 4545 CORDATA PARKWAY, SUITE 1F | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | MD00030270 | WA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 208000000X | MD00030270 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1083229 | 05 | WA | MEDICAID |