Provider Demographics
NPI:1003204082
Name:ECKENRODE, DEREK
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:ECKENRODE
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 1:129 ELIZABETH WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BETHANY
Mailing Address - State:DE
Mailing Address - Zip Code:19930-9667
Mailing Address - Country:US
Mailing Address - Phone:443-956-7031
Mailing Address - Fax:
Practice Address - Street 1:424 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1462
Practice Address - Country:US
Practice Address - Phone:302-645-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR180751163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse