Provider Demographics
NPI:1326023359
Name:EATON, DOUGLAS OW (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:OW
Last Name:EATON
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 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-697-5405
Mailing Address - Fax:951-653-3975
Practice Address - Street 1:6405 DAY ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0901
Practice Address - Country:US
Practice Address - Phone:951-697-5405
Practice Address - Fax:951-697-5687
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31887ZOtherGROUP PTAN
006662510Medicare ID - Type Unspecified
F17595Medicare UPIN