Provider Demographics
NPI:1437122777
Name:EISDORFER, STACEY (OT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:EISDORFER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8181 NW 36 STREET
Mailing Address - Street 2:UNIT 4
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:305-591-9181
Practice Address - Street 1:8181 NW 36 STREET
Practice Address - Street 2:UNIT 4
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:305-591-9108
Practice Address - Fax:305-591-9181
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z9501Medicare ID - Type Unspecified