Provider Demographics
NPI:1629136387
Name:EISEN, NANCY J (DO)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:EISEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:1507 RIVERY BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3058
Practice Address - Country:US
Practice Address - Phone:512-509-9550
Practice Address - Fax:512-509-9555
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00770770OtherRRMCR
TX142166104Medicaid
TX142166103Medicaid
TX8993B7Medicare ID - Type Unspecified
TX142166104Medicaid
TXH15000Medicare UPIN