Provider Demographics
NPI:1932119955
Name:EISENBERG, MARC S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:S
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 1:56 FRANKLIN ST
Mailing Address - Street 2:ATTN LABORATORY
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1221
Mailing Address - Country:US
Mailing Address - Phone:203-709-6053
Mailing Address - Fax:203-709-3156
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:ATTN LABORATORY
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1221
Practice Address - Country:US
Practice Address - Phone:203-709-6053
Practice Address - Fax:203-709-3156
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT015075207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001150755Medicaid
CT2200000354Medicare ID - Type Unspecified
F01116Medicare UPIN