Provider Demographics
NPI:1619020468
Name:EASTHAM, EDWARD D (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:D
Last Name:EASTHAM
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 1:1370 GATEWAY BLVD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129
Mailing Address - Country:US
Mailing Address - Phone:615-890-9008
Mailing Address - Fax:615-890-0193
Practice Address - Street 1:1370 GATEWAY BLVD.
Practice Address - Street 2:SUITE 110
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129
Practice Address - Country:US
Practice Address - Phone:615-890-9008
Practice Address - Fax:615-890-0193
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21198208000000X
TNMD021198208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3896888Medicaid
TN3896888Medicaid