Provider Demographics
NPI:1629397245
Name:EICKENHORST, DANIEL R (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:EICKENHORST
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:816 W CANNON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3146
Practice Address - Country:US
Practice Address - Phone:817-321-0937
Practice Address - Fax:469-522-6889
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012580112085R0202X
TXQ02502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology