Provider Demographics
NPI:1427068030
Name:EATON, BRADFORD JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:JOHN
Last Name:EATON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15744 SUNRISE TRL
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9034
Mailing Address - Country:US
Mailing Address - Phone:574-277-2887
Mailing Address - Fax:
Practice Address - Street 1:314 W CATALPA DR
Practice Address - Street 2:SUITE E
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3194
Practice Address - Country:US
Practice Address - Phone:574-254-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041020A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN203300EMedicare ID - Type Unspecified