=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629006218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN ECKFELDT M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 10/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 DELAWARE STREET SE, 760 MAYO MEMORIAL BUILDING UNIVERSITY OF MINNESOTA PHYSICIANS
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-626-0622
-----------------------------------------------------
Fax | 612-626-2696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 DELAWARE STREET SE MMC 609 UNIVERSITY OF MINNESOTA PHYSICIANS
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-626-0622
-----------------------------------------------------
Fax | 612-626-2696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0105X
-----------------------------------------------------
Taxonomy Name | Clinical Pathology/Laboratory Medicine Physician
-----------------------------------------------------
License Number | 23510
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------