Provider Demographics
NPI:1366490682
Name:EISEN, ALEXANDER MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:MARK
Last Name:EISEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:105 E WATTS ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2511
Practice Address - Country:US
Practice Address - Phone:334-393-5437
Practice Address - Fax:334-393-4185
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201876208000000X, 208D00000X
OH5800150208000000X
ALDO.1311208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102201876Medicaid
AL146239Medicaid