Provider Demographics
NPI:1992800486
Name:EICHENWALD, THERESA FELICIA (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:FELICIA
Last Name:EICHENWALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12200 PARK CENTRAL DRIVE
Mailing Address - Street 2:STE 150
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251
Mailing Address - Country:US
Mailing Address - Phone:469-804-8323
Mailing Address - Fax:469-804-8324
Practice Address - Street 1:12200 PARK CENTRAL DRIVE
Practice Address - Street 2:STE 150
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251
Practice Address - Country:US
Practice Address - Phone:469-804-8323
Practice Address - Fax:469-804-8324
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146607002Medicaid
260341853001OtherTRICARE SOUTH
8BW701OtherBCBS OF TX
04-60996OtherEVERCARE
8BW701OtherBCBS OF TX
260341853001OtherTRICARE SOUTH
8L4531Medicare PIN