Provider Demographics
NPI:1942799804
Name:RECKNAGEL, JOHNATHON (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:
Last Name:RECKNAGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E PETTIGREW ST APT 559
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3896
Mailing Address - Country:US
Mailing Address - Phone:734-478-6731
Mailing Address - Fax:
Practice Address - Street 1:4414 LAKE BOONE TRL STE 308
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7514
Practice Address - Country:US
Practice Address - Phone:919-781-7450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-01254207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty