Provider Demographics
NPI:1215026273
Name:EITZEN, JOHN BRADLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:EITZEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73737-2009
Mailing Address - Country:US
Mailing Address - Phone:580-227-4200
Mailing Address - Fax:580-234-6851
Practice Address - Street 1:523 S INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5631
Practice Address - Country:US
Practice Address - Phone:580-237-5007
Practice Address - Fax:580-234-6851
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3805111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor