Provider Demographics
NPI:1003234048
Name:ECKENRODE, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:ECKENRODE
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 1:30 STEVENS ST STE D
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3859
Mailing Address - Country:US
Mailing Address - Phone:203-852-2406
Mailing Address - Fax:203-899-5281
Practice Address - Street 1:30 STEVENS ST STE D
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3859
Practice Address - Country:US
Practice Address - Phone:203-852-2406
Practice Address - Fax:203-899-5281
Is Sole Proprietor?:No
Enumeration Date:2014-04-05
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2884182086S0102X
NJ25MA110528002086S0102X
390200000X
CT1.0716682086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program