Healthcare Provider Details

I. General information

NPI: 1801032602
Provider Name (Legal Business Name): RANDY L ECCLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 VIRGINIA MALLORY DR
CHANTILLY VA
20151-3974
US

IV. Provider business mailing address

3975 VIRGINIA MALLORY DR
CHANTILLY VA
20151-3974
US

V. Phone/Fax

Practice location:
  • Phone: 703-272-5794
  • Fax: 703-272-5650
Mailing address:
  • Phone: 703-272-5794
  • Fax: 703-272-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK3573
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101235804
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: