Provider Demographics
NPI:1720129539
Name:EASTRIDGE, MICHAEL D (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:EASTRIDGE
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 1:275 96TH AVE N
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2504
Mailing Address - Country:US
Mailing Address - Phone:727-579-0080
Mailing Address - Fax:727-578-2542
Practice Address - Street 1:275 96TH AVE N
Practice Address - Street 2:SUITE 3
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2504
Practice Address - Country:US
Practice Address - Phone:727-579-0080
Practice Address - Fax:727-578-2542
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003431103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75664Medicare ID - Type Unspecified