Provider Demographics
NPI:1891880670
Name:ECKERT, THEODORE III (CRNA)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:ECKERT
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:#202
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-922-9501
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165695367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA297579OtherAMERIGROUP
VA139180OtherANTHEM
VA1891880670Medicaid
VA562605OtherNCPPO
DCK142-0002OtherCAREFIRST
VA139180OtherANTHEM
VA007954F81Medicare ID - Type Unspecified