Basic Information
| Provider Information | |||||||||
| NPI: | 1093961971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EICKSTAEDT | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1940 STONEGATE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA HLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352422541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059779876 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1940 STONEGATE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA HLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352422541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059779876 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 08/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 7120 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 71487 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | 51900 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207N00000X | 42342 | AL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | IA | MEDICAID | P01071102 | 01 | MN | RAIL ROAD - MEDICARE | OTHER | ENROLLED | 05 | MN | MEDICAID |