1821227562 NPI number — MARK E EASTHAM M D A PROFESSIONAL CORPORATION

Table of content: (NPI 1821227562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821227562 NPI number — MARK E EASTHAM M D A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK E EASTHAM M D A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821227562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 SAMARITAN DR STE 508
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95124-4014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-315-1814
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 BON AIR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENBRAE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94904-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-925-7220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EASTHAM
Authorized Official First Name:
MARK
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
408-315-1814

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  G65379 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ01314Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICARE PIN".