Provider Demographics
NPI:1669626552
Name:EASON, TERRELL W (OD)
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:W
Last Name:EASON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:TERRELL
Other - Middle Name:W
Other - Last Name:EASON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:12102 PINE ROW LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1621
Mailing Address - Country:US
Mailing Address - Phone:810-694-0162
Mailing Address - Fax:
Practice Address - Street 1:4165 E COURT ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1717
Practice Address - Country:US
Practice Address - Phone:810-694-0162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2010-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002302152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM12524Medicare UPIN