Provider Demographics
NPI:1982652988
Name:ECKERT, RICHARD RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RUSSELL
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 1:4370 STARKEY RD
Mailing Address - Street 2:SUITE 4-C
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0603
Mailing Address - Country:US
Mailing Address - Phone:540-989-4100
Mailing Address - Fax:540-989-3667
Practice Address - Street 1:4370 STARKEY RD
Practice Address - Street 2:SUITE 4-C
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0603
Practice Address - Country:US
Practice Address - Phone:540-989-4100
Practice Address - Fax:540-989-3667
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-047832174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA222413OtherSOUTHERN HEALTH
VA217216OtherANTHEM
VA542009280-01OtherJOHN DEERE
VA0004252599OtherAETNA PIN #
VA217216OtherANTHEM
VAE47071Medicare UPIN
VA4004690001Medicare NSC