Provider Demographics
NPI:1912948548
Name:EATON, KATHLEEN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:EATON
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 1:5 FIRST VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374
Mailing Address - Country:US
Mailing Address - Phone:910-295-6831
Mailing Address - Fax:
Practice Address - Street 1:5 FIRST VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-295-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57887208100000X
NC2006-00044208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD686801100Medicaid
NC5903767Medicaid
MDF97357Medicare UPIN
NCF97357Medicare UPIN
MDKR82B913Medicare ID - Type Unspecified
MD686801100Medicaid