Provider Demographics
NPI:1427168517
Name:ETHERIDGE, EUGENE WESLEY JR (DC)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:WESLEY
Last Name:ETHERIDGE
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:GENE
Other - Middle Name:WESLEY
Other - Last Name:ETHERIDGE
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:620 WOODBINE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803
Mailing Address - Country:US
Mailing Address - Phone:812-877-0070
Mailing Address - Fax:
Practice Address - Street 1:631 SOUTH 25TH STREET
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803
Practice Address - Country:US
Practice Address - Phone:812-232-8803
Practice Address - Fax:812-232-8803
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08001352OtherALL OTHERS
IN000000093143OtherANTHEM BLUE CROSS BLUE SH
IN5982232OtherAETNA
IN000000093143OtherANTHEM BLUE CROSS BLUE SH