Provider Demographics
NPI:1851390322
Name:ECKLIND, JERROLD RANDALL (DO)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:RANDALL
Last Name:ECKLIND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-4542
Mailing Address - Country:US
Mailing Address - Phone:352-643-6699
Mailing Address - Fax:
Practice Address - Street 1:300 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-4542
Practice Address - Country:US
Practice Address - Phone:352-643-6699
Practice Address - Fax:888-675-8377
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJM261OtherMEDICARE
FL017234800Medicaid