Healthcare Provider Details

I. General information

NPI: 1730364647
Provider Name (Legal Business Name): GARY D EATON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 BETHEL ST
COLUMBIA MO
65203-5603
US

IV. Provider business mailing address

3705 BETHEL ST
COLUMBIA MO
65203-5603
US

V. Phone/Fax

Practice location:
  • Phone: 573-447-2621
  • Fax:
Mailing address:
  • Phone: 573-447-2621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number108444
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number108444
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: