Healthcare Provider Details

I. General information

NPI: 1902875727
Provider Name (Legal Business Name): JOHN T GENECZKO JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TRENT DR 3662 DUMC
DURHAM NC
27710-2479
US

IV. Provider business mailing address

PO BOX 3662
DURHAM NC
27710-0001
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-1817
  • Fax: 919-681-8147
Mailing address:
  • Phone: 919-684-1817
  • Fax: 919-681-8147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01036161A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: