Provider Demographics
NPI:1295771053
Name:EASON, MARVIN L (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:L
Last Name:EASON
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:PO BOX 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3638
Practice Address - Country:US
Practice Address - Phone:423-837-9500
Practice Address - Fax:865-539-8008
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD12900207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3809908Medicaid
TN3045821OtherBLUE CROSS
TNP00285998OtherRAILROAD MEDICARE
TN3070472OtherBCBS OF TENNESSEE
TN3809907Medicaid
TN3070472OtherBCBS OF TENNESSEE
TN3809908Medicare PIN
TN3045821OtherBLUE CROSS