Healthcare Provider Details

I. General information

NPI: 1700871613
Provider Name (Legal Business Name): DAVID EVERETT EASTERDAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 E CHERRY ST
TROY MO
63379-1503
US

IV. Provider business mailing address

PO BOX 249
TROY MO
63379-0249
US

V. Phone/Fax

Practice location:
  • Phone: 636-528-6755
  • Fax: 636-528-6965
Mailing address:
  • Phone: 636-528-6755
  • Fax: 636-528-6965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number108479
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: