Provider Demographics
NPI:1861475402
Name:EASTIN, EMORY LEVON (MD)
Entity Type:Individual
Prefix:DR
First Name:EMORY
Middle Name:LEVON
Last Name:EASTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EMORY
Other - Middle Name:LEVON
Other - Last Name:EASTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1686 SKYLYN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1058
Practice Address - Country:US
Practice Address - Phone:864-585-3456
Practice Address - Fax:864-585-3209
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4095207V00000X
SC29390207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00387008GOtherMEDICARE RAILROAD PTAN#
SC293907Medicaid
SCP00708630OtherRR MEDICARE
SCG305233365Medicare PIN
GAP00387008GOtherMEDICARE RAILROAD PTAN#
SCG30523Medicare UPIN
SC293907Medicaid