Provider Demographics
NPI:1730172925
Name:EASTMAN, JAY W (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:W
Last Name:EASTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:30795 23 MILE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5721
Mailing Address - Country:US
Mailing Address - Phone:586-421-1740
Mailing Address - Fax:586-421-1744
Practice Address - Street 1:30795 23 MILE RD STE 202
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-5721
Practice Address - Country:US
Practice Address - Phone:586-421-1740
Practice Address - Fax:586-421-1744
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJE031896208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350F314450OtherBLUE CROSS AND BLUE SHIEL
MI4332911OtherAETNA
MI4324769Medicaid
MIP41188OtherBLUE CARE NETWORK
MIB9380OtherMCARE
MI350F314450OtherBLUE CROSS AND BLUE SHIEL