Provider Demographics
NPI:1538250899
Name:EASTMAN, MARK ELLIOTT (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLIOTT
Last Name:EASTMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:GERALDINE
Other - Middle Name:TERES
Other - Last Name:O'SHEA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:235 NEW YORK RANCH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-9403
Mailing Address - Country:US
Mailing Address - Phone:209-257-1057
Mailing Address - Fax:209-257-1058
Practice Address - Street 1:235 NEW YORK RANCH RD
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9403
Practice Address - Country:US
Practice Address - Phone:209-257-1057
Practice Address - Fax:209-257-1058
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7345207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH06537Medicare UPIN