Provider Demographics
NPI:1184773582
Name:EISON, THEODORE MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MATTHEW
Last Name:EISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE A115
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3547
Practice Address - Country:US
Practice Address - Phone:864-454-5105
Practice Address - Fax:864-454-5689
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN425342080P0210X
SC351222080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I02026Medicare UPIN