Provider Demographics
NPI:1982444824
Name:ECKBURG, MICAH DOMINIC I (PSS)
Entity type:Individual
Prefix:MR
First Name:MICAH
Middle Name:DOMINIC
Last Name:ECKBURG
Suffix:I
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82272 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-9861
Mailing Address - Country:US
Mailing Address - Phone:541-206-7673
Mailing Address - Fax:
Practice Address - Street 1:715 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2502
Practice Address - Country:US
Practice Address - Phone:541-344-3574
Practice Address - Fax:541-344-5652
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR111140175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist