Provider Demographics
NPI:1538118559
Name:EIDEN, JEFFREY S (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:EIDEN
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 1:1740 N PERRY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:OTTAWA
Mailing Address - State:OH
Mailing Address - Zip Code:45875-1173
Mailing Address - Country:US
Mailing Address - Phone:419-523-0012
Mailing Address - Fax:419-523-3416
Practice Address - Street 1:1740 N PERRY ST
Practice Address - Street 2:SUITE A
Practice Address - City:OTTAWA
Practice Address - State:OH
Practice Address - Zip Code:45875-1173
Practice Address - Country:US
Practice Address - Phone:419-523-0012
Practice Address - Fax:419-523-3416
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000550106OtherANTHEM BC/BS
OHP00170782OtherRAILROAD CARE
OH2118381Medicaid
OHP00472596OtherRAILROAD CARE
OH000000344042OtherANTHEM BC/BS
OH728147OtherBUCKEYE
OH000000550106OtherANTHEM BC/BS
G98715Medicare UPIN
OH0884438Medicare PIN