MEDICARE: DR. SAMUEL BLAKE ECKER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	6858A	WY
2	207N00000X	Dermatology Physician	0061328	CO

General Provider Information

NPI Number	:	1033555230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL BLAKE ECKER D.O.

Provider Business Mailing Address
First Line	:	2710 WESTRIDGE CT
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-6503
Country	:	US
Telephone Number	:	970-682-3377
Fax Number	:	970-682-3340

Provider Business Practice Location Address
First Line	:	204 MCCOLLUM ST STE 106E
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5151
Country	:	US
Telephone Number	:	970-682-3377
Fax Number	:	970-682-3340

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2013
Last Update Date	:	09/27/2021

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