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General NPI Number Information
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NPI Number | 1730172925
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Entity Type | Individual
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Provider Name | JAY W EASTMAN M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/24/2005
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Last Update Date | 06/17/2020
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Provider Practice Location Address
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Address Line | 30795 23 MILE RD STE 202
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City | CHESTERFIELD
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State | MI
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Zip | 48047-5721
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Country | US
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Telephone | 586-421-1740
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Fax | 586-421-1744
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Provider Business Mailing Address
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Address Line | 30795 23 MILE RD STE 202
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City | CHESTERFIELD
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State | MI
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Zip | 48047-5721
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Country | US
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Telephone | 586-421-1740
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Fax | 586-421-1744
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | JE031896
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License Number State | MI
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