Healthcare Provider Details

I. General information

NPI: 1114555729
Provider Name (Legal Business Name): MATTHEW EASTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2689
US

IV. Provider business mailing address

2799 W GRAND BLVD # K12
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-1601
  • Fax:
Mailing address:
  • Phone: 313-916-2181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301517818
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA203811
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: