Healthcare Provider Details

I. General information

NPI: 1881610376
Provider Name (Legal Business Name): MARK EDWARD EASTHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 SAMARITAN DR SUITE 605
SAN JOSE CA
95124-4006
US

IV. Provider business mailing address

2505 SAMARITAN DR SUITE 605
SAN JOSE CA
95124-4006
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-0133
  • Fax: 408-358-8134
Mailing address:
  • Phone: 408-358-0133
  • Fax: 408-358-8134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG65379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: