Provider Demographics
NPI:1871546960
Name:ISENBERG, MICHAEL T (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:ISENBERG
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 1:7900 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4128
Mailing Address - Country:US
Mailing Address - Phone:260-969-7100
Mailing Address - Fax:260-969-7264
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-969-7100
Practice Address - Fax:260-969-7264
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024412207RG0100X
IN01024412A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100355800Medicaid
IN100355800Medicaid
IN925060JMedicare PIN