Provider Demographics
NPI:1548253545
Name:EASTON, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:EASTON
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:PO BOX 6514
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-6514
Mailing Address - Country:US
Mailing Address - Phone:231-922-9270
Mailing Address - Fax:231-922-9271
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-340-1211
Practice Address - Fax:989-340-1214
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICE043624207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2900400781OtherBCBSM INDIVIDUAL #
MICE043624OtherSTATE LICENSE
MI4113460Medicaid
MI110190089OtherRR MEDICARE #
MI0Z47602008Medicare ID - Type Unspecified
MI4113460Medicaid