Healthcare Provider Details

I. General information

NPI: 1225026990
Provider Name (Legal Business Name): ALEJANDRO A EISMA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SOUTH DRIVE WINNEBAGO MENTAL HEALTH INSTITUTE
WINNEBAGO WI
54985-0009
US

IV. Provider business mailing address

1855 S KOELLER ST
OSHKOSH WI
54902-6186
US

V. Phone/Fax

Practice location:
  • Phone: 920-235-4910
  • Fax: 920-236-2931
Mailing address:
  • Phone: 920-223-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number43119
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: