Provider Demographics
NPI:1043724693
Name:SOURS, COREY TAIT EASTHAM (RT (R)(CT)(ARRT))
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:TAIT EASTHAM
Last Name:SOURS
Suffix:
Gender:M
Credentials:RT (R)(CT)(ARRT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 PINTAIL AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-6215
Mailing Address - Country:US
Mailing Address - Phone:970-623-9293
Mailing Address - Fax:
Practice Address - Street 1:2121 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6428
Practice Address - Country:US
Practice Address - Phone:970-242-0731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5107292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology