Provider Demographics
NPI:1336326289
Name:MARC W. EATON, PH.D., P.C.
Entity Type:Organization
Organization Name:MARC W. EATON, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:WELLS
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:912-283-6629
Mailing Address - Street 1:1227 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4524
Mailing Address - Country:US
Mailing Address - Phone:912-283-6629
Mailing Address - Fax:912-283-5980
Practice Address - Street 1:1227 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4524
Practice Address - Country:US
Practice Address - Phone:912-283-6629
Practice Address - Fax:912-283-5980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000673103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR12499Medicare UPIN