Provider Demographics
NPI:1942663554
Name:EAGLESTON, S JUSTIN MICHAEL
Entity type:Individual
Prefix:
First Name:S JUSTIN
Middle Name:MICHAEL
Last Name:EAGLESTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:419-462-3485
Mailing Address - Fax:
Practice Address - Street 1:715 RICHLAND MALL
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-3802
Practice Address - Country:US
Practice Address - Phone:567-307-7854
Practice Address - Fax:567-307-7855
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.148903208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery