Provider Demographics
NPI:1265574719
Name:EATON, THOMAS L (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:EATON
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 1:11725 N PORT WASHINGTON RD
Mailing Address - Street 2:STE 250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3485
Mailing Address - Country:US
Mailing Address - Phone:262-240-9640
Mailing Address - Fax:262-240-9657
Practice Address - Street 1:11725 N PORT WASHINGTON RD
Practice Address - Street 2:STE 250
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3485
Practice Address - Country:US
Practice Address - Phone:262-240-9640
Practice Address - Fax:262-240-9657
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40449-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE29395Medicare UPIN