Provider Demographics
NPI:1992130710
Name:EASTHAM, MARK LOUIS (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LOUIS
Last Name:EASTHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 HIGH RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-6848
Mailing Address - Country:US
Mailing Address - Phone:509-951-1484
Mailing Address - Fax:
Practice Address - Street 1:3229 HIGH RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-6848
Practice Address - Country:US
Practice Address - Phone:509-951-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1234139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist