Provider Demographics
NPI:1336494772
Name:EATON, MATTHEW T (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:EATON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S CREEK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-9472
Mailing Address - Country:US
Mailing Address - Phone:606-348-3365
Mailing Address - Fax:606-348-8496
Practice Address - Street 1:1 S CREEK DR STE 102
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633
Practice Address - Country:US
Practice Address - Phone:606-348-3365
Practice Address - Fax:606-340-3413
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116025303390200000X
KY03959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0169Medicare PIN