Provider Demographics
NPI:1558568931
Name:EASTIN, TARA JEAN (DO)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JEAN
Last Name:EASTIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1009
Mailing Address - Fax:
Practice Address - Street 1:33720 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-4255
Practice Address - Country:US
Practice Address - Phone:586-294-5210
Practice Address - Fax:586-294-0215
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDO034313207RH0002X
MI5101017326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MITE017326OtherMI LICENSE
DCDO034313OtherLICENSE