Healthcare Provider Details

I. General information

NPI: 1922448612
Provider Name (Legal Business Name): JOSEPH THEODORE ECKELKAMP JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9759 MANCHESTER RD
SAINT LOUIS MO
63119-1346
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-669-2219
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2016006200
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: