Provider Demographics
NPI:1730150897
Name:DISBROW, ERIC C (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:C
Last Name:DISBROW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-3608
Mailing Address - Country:US
Mailing Address - Phone:209-358-5611
Mailing Address - Fax:209-357-0219
Practice Address - Street 1:1775 3RD ST
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-3608
Practice Address - Country:US
Practice Address - Phone:209-358-5611
Practice Address - Fax:209-358-0219
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ77315ZOtherMEDI-CAL CALIFORNIA
CA080025592OtherMEDICARE RAILROAD
CA080025592OtherMEDICARE RAILROAD
CAA41150Medicare UPIN
CA0323680001Medicare NSC