Provider Demographics
NPI:1659376929
Name:EISENBERG, KENNETH LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LAWRENCE
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:STE 212
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5008
Mailing Address - Country:US
Mailing Address - Phone:915-532-3977
Mailing Address - Fax:915-532-5866
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:STE 212
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5008
Practice Address - Country:US
Practice Address - Phone:915-532-3977
Practice Address - Fax:915-532-5866
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1381208G00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133925105Medicaid
TX133925105Medicaid
83K053Medicare ID - Type Unspecified