Healthcare Provider Details

I. General information

NPI: 1730146739
Provider Name (Legal Business Name): JEFFREY CHARLES EASOM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3051 WATSON BLVD SUITE 400
WARNER ROBINS GA
31093-8536
US

IV. Provider business mailing address

3051 WATSON BLVD SUITE 400
WARNER ROBINS GA
31093-8536
US

V. Phone/Fax

Practice location:
  • Phone: 478-953-4563
  • Fax: 478-953-4616
Mailing address:
  • Phone: 478-953-4563
  • Fax: 478-953-4683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number054269
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: