Provider Demographics
NPI:1457338527
Name:EASTES, GARY DEAN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DEAN
Last Name:EASTES
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 1:14269 RR 2338
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-4112
Mailing Address - Country:US
Mailing Address - Phone:254-371-1060
Mailing Address - Fax:254-288-8875
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-392-2026
Practice Address - Fax:970-392-2027
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8202208800000X, 174400000X
CODR-38516208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156562401Medicaid
TX8G3958Medicare PIN
VAGC1100Medicare PIN
B68868Medicare UPIN
TX156562401Medicaid