Provider Demographics
NPI:1841396785
Name:EATON, BRENDA SURAE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:SURAE
Last Name:EATON
Suffix:
Gender:F
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:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6208
Practice Address - Street 1:2909 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4300
Practice Address - Country:US
Practice Address - Phone:517-364-8686
Practice Address - Fax:517-364-8685
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2753567Medicaid
MI0803331331OtherBCBS INDIVIDUAL PIN
MI0803331331OtherBCBS INDIVIDUAL PIN
MIOC36170003Medicare ID - Type Unspecified