=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417283409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALIZA VAZANA EISEN DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2009
-----------------------------------------------------
Last Update Date | 02/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 RITTENHOUSE PL
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-642-8837
-----------------------------------------------------
Fax | 610-642-1607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 RITTENHOUSE PL
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-642-8837
-----------------------------------------------------
Fax | 610-642-1607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | SC006113
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | SC006113
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------