Provider Demographics
NPI:1669686747
Name:MARK E. EASTHAM, M.D.
Entity Type:Organization
Organization Name:MARK E. EASTHAM, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:EASTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-241-2968
Mailing Address - Street 1:2505 SAMARITAN DR
Mailing Address - Street 2:SUITE 508
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2505 SAMARITAN DR
Practice Address - Street 2:SUITE 508
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4006
Practice Address - Country:US
Practice Address - Phone:408-241-2968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65379207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G653790Medicaid
E30309Medicare UPIN
CA00G653790Medicaid