Provider Demographics
NPI:1235247784
Name:KNACKSTEDT, JAMES J (M D)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:J
Last Name:KNACKSTEDT
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 WILLAGILLESPIE RD STE 300C
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2162
Mailing Address - Country:US
Mailing Address - Phone:541-302-1420
Mailing Address - Fax:541-485-7881
Practice Address - Street 1:995 WILLAGILLESPIE RD STE 300C
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2162
Practice Address - Country:US
Practice Address - Phone:541-302-1420
Practice Address - Fax:541-485-7881
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14759174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR180356Medicaid
ORR112990Medicare PIN
OR180356Medicaid