Healthcare Provider Details

I. General information

NPI: 1821000704
Provider Name (Legal Business Name): LARRY ECKSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2760 29TH ST SUITE 2-D
BOULDER CO
80301-1214
US

IV. Provider business mailing address

PO BOX 21150
BOULDER CO
80308-4150
US

V. Phone/Fax

Practice location:
  • Phone: 303-546-9158
  • Fax: 303-546-9107
Mailing address:
  • Phone: 303-546-9158
  • Fax: 303-546-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number33042
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01330422
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: