Provider Demographics
NPI:1437129939
Name:EASTMAN, WILFRED WALTER JR (MD/)
Entity Type:Individual
Prefix:DR
First Name:WILFRED
Middle Name:WALTER
Last Name:EASTMAN
Suffix:JR
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 1:444 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3450
Mailing Address - Country:US
Mailing Address - Phone:530-842-1267
Mailing Address - Fax:530-842-9121
Practice Address - Street 1:475 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3474
Practice Address - Country:US
Practice Address - Phone:530-842-1267
Practice Address - Fax:530-842-9121
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G396230207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACJ570ZOtherPTAN
CA1437129939Medicaid
CA200018580OtherMEDICARE RAILROAD
CACMS116890OtherMTC CONSULTANT
CACMS116890Medicaid
CACMS116890OtherCALIFORNIA CHILDREN'S SERVICES CCS
CA200018580OtherMEDICARE RAILROAD
CA00G396230Medicare ID - Type Unspecified
CACMS116890OtherCALIFORNIA CHILDREN'S SERVICES CCS