Provider Demographics
NPI:1932145760
Name:EISENBERGER, ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:EISENBERGER
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:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-9010
Mailing Address - Country:US
Mailing Address - Phone:631-232-4000
Mailing Address - Fax:631-851-9225
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-4027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2218462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02785151Medicaid
NY02785151Medicaid