Provider Demographics
NPI:1215937388
Name:ECKERLING, GARRETT M (MD)
Entity type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:M
Last Name:ECKERLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BANK ST STE 256
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6518
Mailing Address - Country:US
Mailing Address - Phone:530-277-5207
Mailing Address - Fax:530-432-3130
Practice Address - Street 1:111 BANK ST STE 256
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6518
Practice Address - Country:US
Practice Address - Phone:530-277-5207
Practice Address - Fax:530-432-3130
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0947254OtherFEDERAL CLIA #
CA00A611770OtherBLUE SHIELD PIN #
CA1215937388Medicaid
CA00A611770OtherBLUE SHIELD PIN #