Provider Demographics
NPI:1861471369
Name:EASTLACK, ROBERT K (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
Last Name:EASTLACK
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:FILE # 54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4433
Mailing Address - Country:US
Mailing Address - Phone:858-784-5888
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-7988
Practice Address - Fax:858-554-8231
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47895207X00000X
CAA73162207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A731620Medicaid
MN093411900Medicaid
CAWA73162DMedicare PIN
I36736Medicare UPIN
CAI36736Medicare UPIN
MN200002355Medicare ID - Type Unspecified