Provider Demographics
NPI:1912944083
Name:HARDING-MARIN, EASTLYN E (MD)
Entity Type:Individual
Prefix:
First Name:EASTLYN
Middle Name:E
Last Name:HARDING-MARIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2721
Mailing Address - Country:US
Mailing Address - Phone:770-507-4554
Mailing Address - Fax:770-507-6413
Practice Address - Street 1:211 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2721
Practice Address - Country:US
Practice Address - Phone:770-507-4554
Practice Address - Fax:770-507-6413
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00319023OtherRAILROAD MEDICARE
GAP00319023OtherRAILROAD MEDICARE
GA08CBBNNMedicare PIN