Provider Demographics
NPI:1023032190
Name:EISEN, RICHARD N (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:N
Last Name:EISEN
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:PO BOX 42210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-2210
Mailing Address - Country:US
Mailing Address - Phone:623-266-7770
Mailing Address - Fax:623-322-4639
Practice Address - Street 1:5555 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4622
Practice Address - Country:US
Practice Address - Phone:602-685-5211
Practice Address - Fax:602-685-5325
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50419207ZP0101X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ039165Medicaid
CT220000407Medicare ID - Type Unspecified