Provider Demographics
NPI:1417577834
Name:EISENGA, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:EISENGA
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 1:6012 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-1524
Mailing Address - Country:US
Mailing Address - Phone:616-446-9183
Mailing Address - Fax:
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2017
Practice Address - Country:US
Practice Address - Phone:214-820-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-26
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program