Provider Demographics
NPI:1326088121
Name:EASTBURN, TED E (MD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:E
Last Name:EASTBURN
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:PO BOX 9809
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80932-0809
Mailing Address - Country:US
Mailing Address - Phone:719-635-7172
Mailing Address - Fax:719-444-3771
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:SUITE 700
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-635-7172
Practice Address - Fax:719-444-3771
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25772207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE60013Medicare UPIN
COCO303317Medicare PIN
COC155918Medicare PIN