Basic Information
| Provider Information | |||||||||
| NPI: | 1114961984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EYRE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 94220 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974447756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476621 | ||||||||
| FaxNumber: | 5412472435 | ||||||||
| Practice Location | |||||||||
| Address1: | 94220 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974447756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476621 | ||||||||
| FaxNumber: | 5412472435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | MD10680 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD10680 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 256610 | 05 | OR | MEDICAID |