Provider Demographics
NPI:1154359818
Name:EASTERLING, STANLEY R (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:R
Last Name:EASTERLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 URBAN CENTER DR
Mailing Address - Street 2:STE 600
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2584
Mailing Address - Country:US
Mailing Address - Phone:601-638-7271
Mailing Address - Fax:
Practice Address - Street 1:104 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2825
Practice Address - Country:US
Practice Address - Phone:601-638-7271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1383872Medicaid
MS00114107Medicaid
MS4216184OtherAETNA
MS4216184OtherAETNA
MS4216184OtherAETNA
MS$$$$$$$$$COtherBCBS
LA1383872Medicaid
MS080003923Medicare PIN