Healthcare Provider Details

I. General information

NPI: 1003137084
Provider Name (Legal Business Name): JASON P EASTLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 11/11/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 MARION ST
COLUMBIA SC
29201-2910
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-5954
  • Fax: 803-296-3076
Mailing address:
  • Phone: 864-522-8614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24394
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberP2434
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number52431
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: