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General NPI Number Information
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NPI Number | 1821227463
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Entity Type | Organization
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Legal Business Name | ROBERT K. EASTLACK MD INC
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Dates
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Enumeration Date | 07/03/2009
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Last Update Date | 07/03/2009
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Provider Practice Location Address
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Address Line | 5265 AMBER VIEW PT
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City | SAN DIEGO
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State | CA
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Zip | 92130-6933
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Country | US
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Telephone | 858-361-1390
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Fax | 858-925-7227
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Provider Business Mailing Address
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Address Line | 5265 AMBER VIEW PT
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City | SAN DIEGO
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State | CA
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Zip | 92130-6933
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Country | US
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Telephone | 858-361-1390
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Fax | 858-925-7227
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. ROBERT KENNETH EASTLACK
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Credential | M.D.
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Telephone | 858-361-1390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A73162
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License Number State | CA
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