Provider Demographics
NPI:1194713669
Name:EASTON, KENNETH J (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:EASTON
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 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:STE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:616-954-6483
Practice Address - Street 1:1111 LEFFINGWELL NE
Practice Address - Street 2:STE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:616-954-6483
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051829207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00240358OtherRR MEDICARE
TX4763007Medicaid
P00240358OtherRR MEDICARE
0D14869Medicare ID - Type Unspecified
TX4763007Medicaid