Provider Demographics
NPI:1215923354
Name:EISNER, JERRY D (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:EISNER
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 1:1400 E. KINCAID ST.
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E. KINCAID ST.
Practice Address - Street 2:SKAGIT REGIONAL CLINICS
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-814-6200
Practice Address - Fax:360-814-6210
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014819207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA263627OtherLABOR & INDUSTRIES
WA8354912Medicaid
WAG8892628Medicare PIN
WA8354912Medicaid
WA1100059Medicare PIN