Provider Demographics
NPI:1396789830
Name:EASLEY, S FOSTER III (DO)
Entity type:Individual
Prefix:DR
First Name:S FOSTER
Middle Name:
Last Name:EASLEY
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:FOSTER
Other - Middle Name:
Other - Last Name:EASLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1530 W. GLENDALE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021
Mailing Address - Country:US
Mailing Address - Phone:602-973-8285
Mailing Address - Fax:602-973-8248
Practice Address - Street 1:1530 W. GLENDALE AVE.
Practice Address - Street 2:SUITE 104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021
Practice Address - Country:US
Practice Address - Phone:602-973-8285
Practice Address - Fax:602-973-8248
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3212207Q00000X, 207QA0401X, 207RA0401X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ579170Medicaid
AZZ140564Medicare PIN
78072Medicare ID - Type Unspecified