Healthcare Provider Details

I. General information

NPI: 1780979088
Provider Name (Legal Business Name): CARRIE ECKSTAM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 NICOLLET AVE S
BLOOMINGTON MN
55420-2824
US

IV. Provider business mailing address

8600 NICOLLET AVE S MAIL STOP 31500A
BLOOMINGTON MN
55420-2824
US

V. Phone/Fax

Practice location:
  • Phone: 952-541-2800
  • Fax: 952-886-7015
Mailing address:
  • Phone: 952-541-2800
  • Fax: 952-886-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number55268
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: