Provider Demographics
NPI:1740206606
Name:ECKERT, DIETER ERNST
Entity Type:Individual
Prefix:
First Name:DIETER
Middle Name:ERNST
Last Name:ECKERT
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 1:150 TEJAS PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-269-1300
Practice Address - Fax:805-269-1387
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG210392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71031FMedicaid
CAW1508EMedicare PIN
CABN628YMedicare PIN
CABN628WMedicare PIN
CABN628ZMedicare PIN
CAW1508CMedicare PIN
CAW1508DMedicare PIN
CABN628XMedicare PIN
CAA90679Medicare UPIN
CA551983Medicare Oscar/Certification
CAW1508Medicare PIN
CAFHC71031FMedicaid
CAW1508AMedicare PIN