Provider Demographics
NPI:1457313439
Name:EASTRIDGE, WESLEY V (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:V
Last Name:EASTRIDGE
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 1:1233 RADCLIFFE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2027
Mailing Address - Country:US
Mailing Address - Phone:423-502-8656
Mailing Address - Fax:
Practice Address - Street 1:1233 RADCLIFFE AVE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2027
Practice Address - Country:US
Practice Address - Phone:423-502-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4046651Medicaid
TN107277OtherBLUE CROSS OF TENNESSEE
274021OtherBLACK LUNG
VA037070OtherANTHEM BLUE CROSS
2622550OtherCIGNA
VA005609879Medicaid
4581788OtherAETNA
VA037073OtherANTHEM BLUE CROSS
621584391OtherTRICARE
TN4401019Medicaid
62158439108OtherUNITED HEALTHCARE
62158439108OtherUNITED HEALTHCARE
A98397Medicare UPIN
VA005609879Medicaid
TN4046651Medicaid
VA080004758Medicare PIN
4581788OtherAETNA
TN4401019Medicaid