Provider Demographics
NPI:1699790857
Name:LACKNER, JONATHAN E (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:E
Last Name:LACKNER
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 1:100 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:855-446-5937
Mailing Address - Fax:740-446-5958
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:855-446-5937
Practice Address - Fax:740-446-5958
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM99-72208800000X
OH35.140970208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM340020617OtherRAILROAD MEDICARE
NMZ3796Medicaid
NM340020617OtherRAILROAD MEDICARE
NMZ3796Medicaid