Provider Demographics
NPI:1093961971
Name:EICKSTAEDT, JOSHUA B (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:B
Last Name:EICKSTAEDT
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 1:200 WELLESLEY TRADE LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-5576
Mailing Address - Country:US
Mailing Address - Phone:919-363-7546
Mailing Address - Fax:919-363-3616
Practice Address - Street 1:5 FIRST VILLAGE DR STE 101
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-9495
Practice Address - Country:US
Practice Address - Phone:910-295-1761
Practice Address - Fax:910-295-2937
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL42342207N00000X
NC2023-00795207ND0101X, 207N00000X, 207ND0101X
MN51900207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNP01071102OtherRAIL ROAD - MEDICARE
MNENROLLEDMedicaid
MNENROLLEDMedicaid