Provider Demographics
NPI:1225026990
Name:EISMA, ALEJANDRO A (MD)
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:A
Last Name:EISMA
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 1:1855 S KOELLER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6186
Mailing Address - Country:US
Mailing Address - Phone:920-223-7100
Mailing Address - Fax:
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:WINNEBAGO MENTAL HEALTH INSTITUTE
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-236-2931
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34115400Medicaid
B80242Medicare UPIN
000000920Medicare PIN
WI34115400Medicaid