Provider Demographics
NPI:1902875727
Name:GENECZKO, JOHN T JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:GENECZKO
Suffix:JR
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:PO BOX 3662
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-0001
Mailing Address - Country:US
Mailing Address - Phone:919-684-1817
Mailing Address - Fax:919-681-8147
Practice Address - Street 1:200 TRENT DR
Practice Address - Street 2:3662 DUMC
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-2479
Practice Address - Country:US
Practice Address - Phone:919-684-1817
Practice Address - Fax:919-681-8147
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036161A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000190914OtherANTHEM PROVIDER NUMBER
IN100085880Medicaid
IN9397086OtherPHCS PID NUMBER
IN10825131OtherCAQH NUMBER
INGE15365010Medicaid
IN9397086OtherPHCS PID NUMBER
IN100085880Medicaid
IN815500NMedicare PIN