Healthcare Provider Details

I. General information

NPI: 1972532760
Provider Name (Legal Business Name): EASTON L MANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 VARNUM ST NE STE 207
WASHINGTON DC
20017-2153
US

IV. Provider business mailing address

1140 VARNUM ST NE STE 207
WASHINGTON DC
20017-2153
US

V. Phone/Fax

Practice location:
  • Phone: 202-526-5300
  • Fax: 202-526-6013
Mailing address:
  • Phone: 202-526-5300
  • Fax: 202-526-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD6154
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: