Provider Demographics
NPI:1881675940
Name:ECKERT, EDWARD RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RANDOLPH
Last Name:ECKERT
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 164106
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78716-4106
Mailing Address - Country:US
Mailing Address - Phone:512-901-1206
Mailing Address - Fax:512-901-1299
Practice Address - Street 1:12221 N MOPAC EXPRESSWAY
Practice Address - Street 2:NAMC DEPARTMENT OF PATHOLOGY
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758
Practice Address - Country:US
Practice Address - Phone:512-901-1206
Practice Address - Fax:512-901-1299
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8089207ZP0102X
LA07208R207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124423802OtherCSHCN
TX124423803Medicaid
TX124423805Medicaid
80P644OtherBCBS OF TEXAS
E14255Medicare UPIN
TX124423803Medicaid
TX124423805Medicaid
TX8L5686Medicare PIN
TX220011232Medicare PIN