Healthcare Provider Details

I. General information

NPI: 1134221252
Provider Name (Legal Business Name): MARTIN JOHN EATON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W MAIN STREET SUITE 102
TUSTIN CA
92780
US

IV. Provider business mailing address

100 S. IMPERIAL HWY
ANAHEIM HILLS CA
92807
US

V. Phone/Fax

Practice location:
  • Phone: 714-730-9355
  • Fax: 714-730-9357
Mailing address:
  • Phone: 714-769-7600
  • Fax: 714-866-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY15533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: