Provider Demographics
NPI:1851373120
Name:EISENBERG, JAMES P (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:EISENBERG
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 1:1100 WILFORD HALL LOOP
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-292-2201
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.043927207Q00000X
OH35043927E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0407590Medicaid
OHEI4025671Medicare ID - Type Unspecified
OH0407590Medicaid