Provider Demographics
NPI:1225451685
Name:EAGLE, DAVID JON (PSYD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JON
Last Name:EAGLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6719 CORAL LEAF LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-6213
Mailing Address - Country:US
Mailing Address - Phone:951-789-9144
Mailing Address - Fax:951-789-9144
Practice Address - Street 1:6719 CORAL LEAF LN
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-6213
Practice Address - Country:US
Practice Address - Phone:951-789-9144
Practice Address - Fax:951-789-9144
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14978103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent