Provider Demographics
NPI:1417251109
Name:BRADFORD J EATON PHD
Entity Type:Organization
Organization Name:BRADFORD J EATON PHD
Other - Org Name:BRADFORD J EATON PHD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:J
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:274-335-8800
Mailing Address - Street 1:15744 SUNRISE TRL
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9034
Mailing Address - Country:US
Mailing Address - Phone:574-335-8800
Mailing Address - Fax:574-335-8801
Practice Address - Street 1:15744 SUNRISE TRL
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9034
Practice Address - Country:US
Practice Address - Phone:574-335-8800
Practice Address - Fax:574-335-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041020A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN203300EMedicare PIN