Provider Demographics
NPI:1801800487
Name:T W EASON OD PC
Entity type:Organization
Organization Name:T W EASON OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:T
Authorized Official - Middle Name:W
Authorized Official - Last Name:EASON
Authorized Official - Suffix:
Authorized Official - Credentials:OD PC
Authorized Official - Phone:810-694-0162
Mailing Address - Street 1:12102 PINE ROW LANE
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439
Mailing Address - Country:US
Mailing Address - Phone:810-694-0162
Mailing Address - Fax:
Practice Address - Street 1:3191 S LINDEN RD
Practice Address - Street 2:SEARS OPTICAL
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-733-4252
Practice Address - Fax:810-733-4216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2010-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002302152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3194131Medicaid
MI3194131Medicaid
MIM12524001Medicare UPIN