Provider Demographics
NPI:1992756506
Name:EISENBERG, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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:PO BOX 30077
Mailing Address - Street 2:DEPT 305
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0077
Mailing Address - Country:US
Mailing Address - Phone:877-243-8416
Mailing Address - Fax:
Practice Address - Street 1:5495 S RAINBOW BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1872
Practice Address - Country:US
Practice Address - Phone:702-477-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV63072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV4208OtherBCBS
NV152974OtherWC
NV200290109Medicaid
NVNV4870OtherBCBS
NV153100OtherWC
NV200290109Medicaid
NVV30WCHKB09Medicare PIN
NV153100OtherWC
NV300057735Medicare PIN
NV152974OtherWC