Provider Demographics
NPI:1427044684
Name:EISEN, THOMAS D (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:EISEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:136 SHERMAN AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5238
Mailing Address - Country:US
Mailing Address - Phone:203-787-0117
Mailing Address - Fax:203-777-3559
Practice Address - Street 1:136 SHERMAN AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5238
Practice Address - Country:US
Practice Address - Phone:203-787-0117
Practice Address - Fax:203-777-3559
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT28182207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001281823Medicaid
CT001281823Medicaid
CT390000152Medicare PIN