Provider Demographics
NPI:1508002544
Name:DEREK LEE EISNOR MD PA
Entity Type:Organization
Organization Name:DEREK LEE EISNOR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:EISNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-254-6218
Mailing Address - Street 1:2080 W EAU GALLIE BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3185
Mailing Address - Country:US
Mailing Address - Phone:321-254-6218
Mailing Address - Fax:321-254-6230
Practice Address - Street 1:2080 W EAU GALLIE BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3185
Practice Address - Country:US
Practice Address - Phone:321-254-6218
Practice Address - Fax:321-254-6230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74231207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255900500Medicaid
FL44898Medicare PIN