Provider Demographics
NPI:1164470480
Name:RECKARD, JUSTIN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:RECKARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:71943 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4848
Mailing Address - Country:US
Mailing Address - Phone:760-776-7600
Mailing Address - Fax:760-776-7640
Practice Address - Street 1:71943 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4848
Practice Address - Country:US
Practice Address - Phone:760-776-7600
Practice Address - Fax:760-776-7640
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120374208600000X
HI13458208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery