Provider Demographics
NPI:1205832854
Name:HAIRSTON, EARLIE OWENS II (DPM)
Entity type:Individual
Prefix:
First Name:EARLIE
Middle Name:OWENS
Last Name:HAIRSTON
Suffix:II
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 CORTEZ BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6897
Mailing Address - Country:US
Mailing Address - Phone:352-683-6618
Mailing Address - Fax:352-683-5722
Practice Address - Street 1:12900 CORTEZ BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6897
Practice Address - Country:US
Practice Address - Phone:352-683-6618
Practice Address - Fax:352-683-5722
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3162213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340486200Medicaid
FL5307680001Medicare NSC
FLV02134Medicare UPIN