Provider Demographics
NPI:1316154982
Name:ECKSTEIN, GREGORY TODD (RN)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:TODD
Last Name:ECKSTEIN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1425 E BLANCO BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6002
Mailing Address - Country:US
Mailing Address - Phone:505-634-3501
Mailing Address - Fax:505-634-3584
Practice Address - Street 1:1201 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5271
Practice Address - Country:US
Practice Address - Phone:505-634-3501
Practice Address - Fax:505-634-3584
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR48383163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64434826Medicaid