Provider Demographics
NPI:1215387576
Name:EGGLESTON, DORTHIA
Entity Type:Individual
Prefix:
First Name:DORTHIA
Middle Name:
Last Name:EGGLESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 GRATIOT AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-2216
Mailing Address - Country:US
Mailing Address - Phone:989-948-3385
Mailing Address - Fax:
Practice Address - Street 1:1203 GRATIOT
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602
Practice Address - Country:US
Practice Address - Phone:989-948-3385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI27011533951744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management