Provider Demographics
NPI:1043300726
Name:ECKHARDT, SUE GAIL (MD)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:GAIL
Last Name:ECKHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 TRINITY ST STOP Z0200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1850
Mailing Address - Country:US
Mailing Address - Phone:512-495-5512
Mailing Address - Fax:
Practice Address - Street 1:1601 TRINITY ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1765
Practice Address - Country:US
Practice Address - Phone:512-495-5512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3090207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87471272Medicaid
CO87471272Medicaid