Provider Demographics
NPI:1629006226
Name:EISMAN, JEROME NORMAN (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:NORMAN
Last Name:EISMAN
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 2878
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2878
Mailing Address - Country:US
Mailing Address - Phone:619-749-7710
Mailing Address - Fax:619-749-7710
Practice Address - Street 1:8851 CENTER DR
Practice Address - Street 2:SUITE 310
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3017
Practice Address - Country:US
Practice Address - Phone:619-749-7710
Practice Address - Fax:619-749-7710
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33319207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88980Medicare UPIN
CAC33319Medicare ID - Type Unspecified