Provider Demographics
NPI:1437238300
Name:EISEN, JONATHAN FARREL (DC)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:FARREL
Last Name:EISEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 MARISA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309
Mailing Address - Country:US
Mailing Address - Phone:718-605-2591
Mailing Address - Fax:
Practice Address - Street 1:224 ROUTE 4 EAST LOWER LEVEL
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-845-5999
Practice Address - Fax:201-845-5999
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008779-1111N00000X
NJ38MC00638000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7452866OtherAETNA
NJ0093581Medicaid
NYC08779-3BOtherW/C BOARD #
NY5897373OtherGHI
NYC08779-3BOtherW/C BOARD #
NYV02674Medicare UPIN
NJ096418Medicare ID - Type Unspecified