Provider Demographics
NPI:1588984363
Name:EISELMAN, MALCOLM (MD)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:EISELMAN
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 1:3650 N. 55TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2344
Mailing Address - Country:US
Mailing Address - Phone:954-961-2034
Mailing Address - Fax:
Practice Address - Street 1:3650 N. 55TH AVENUE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2344
Practice Address - Country:US
Practice Address - Phone:954-961-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD60306Medicare UPIN
FL93049Medicare PIN