=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770580128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN W. EAKIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2005
-----------------------------------------------------
Last Update Date | 03/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1280A MAIN ST
-----------------------------------------------------
City | ALTAVISTA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24517-1465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-309-1165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1204 FENWICK DR
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0101042725
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------