Provider Demographics
NPI:1790756914
Name:EASLEY, JEFFREY ARNOLD (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ARNOLD
Last Name:EASLEY
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 1:4619 COVINGTON RD.
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:419-605-8668
Mailing Address - Fax:419-232-4498
Practice Address - Street 1:4619 COVINGTON RD.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:419-605-8668
Practice Address - Fax:419-232-4498
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073504A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0784441Medicaid
OHEA0668035Medicare ID - Type Unspecified
OH0784441Medicaid