Provider Demographics
NPI:1619948536
Name:EISENSTAT, THEODORE E (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:E
Last Name:EISENSTAT
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 1:3900 PARK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3032
Mailing Address - Country:US
Mailing Address - Phone:732-494-6640
Mailing Address - Fax:732-549-8204
Practice Address - Street 1:3900 PARK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3032
Practice Address - Country:US
Practice Address - Phone:732-494-6640
Practice Address - Fax:732-549-8204
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02494100208600000X
NJ25MA024994100208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1595008Medicaid
NJEI521818Medicare ID - Type Unspecified
NJ1595008Medicaid