Provider Demographics
NPI:1649244872
Name:EASON, GEORGE RICHARD (DPM)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:RICHARD
Last Name:EASON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2269 BONAZA COURT
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8903
Mailing Address - Country:US
Mailing Address - Phone:801-750-0258
Mailing Address - Fax:
Practice Address - Street 1:2269 BONANZA COURT
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8903
Practice Address - Country:US
Practice Address - Phone:801-750-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102804-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000093Medicare ID - Type Unspecified
UT0654970001Medicare NSC
000002817Medicare ID - Type Unspecified
T48822Medicare UPIN