Provider Demographics
NPI:1730146739
Name:EASOM, JEFFREY CHARLES (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CHARLES
Last Name:EASOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 WATSON BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-8536
Mailing Address - Country:US
Mailing Address - Phone:478-953-4563
Mailing Address - Fax:478-953-4683
Practice Address - Street 1:3051 WATSON BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8536
Practice Address - Country:US
Practice Address - Phone:478-953-4563
Practice Address - Fax:478-953-4616
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054269207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA976624642AMedicaid
GA976624642AMedicaid
H92835Medicare UPIN