Provider Demographics
NPI:1134165178
Name:EASTERLY, JEFFERY (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:EASTERLY
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 1:129 MONTGOMERY LN
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-5649
Mailing Address - Country:US
Mailing Address - Phone:865-681-1224
Mailing Address - Fax:
Practice Address - Street 1:129 MONTGOMERY LN
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-5649
Practice Address - Country:US
Practice Address - Phone:865-681-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00238548OtherRR MEDICARE PIN
TN3866200Medicaid
TN3866200Medicaid
TN3866200Medicare ID - Type UnspecifiedLEGACY PIN
TN3717544Medicare ID - Type UnspecifiedLEGACY GROUP