Healthcare Provider Details

I. General information

NPI: 1962564484
Provider Name (Legal Business Name): THOMAS G. ECCLES III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 06/24/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 GEORGIA AVE NW WRAMC BLDG 2 DEPARTMENT OF PEDIATRICS
WASHINGTON DC
20307-0001
US

IV. Provider business mailing address

MEDDAC-BAVARIA CMR 411
APO AE
09112
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-6107
  • Fax: 202-782-0740
Mailing address:
  • Phone: 324-591-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0056915
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: