Provider Demographics
NPI:1447545603
Name:KNACKSTEDT, THOMAS J (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:KNACKSTEDT
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 1:1006 PROCURE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2627
Mailing Address - Country:US
Mailing Address - Phone:919-762-6845
Mailing Address - Fax:919-762-6865
Practice Address - Street 1:1006 PROCURE ST STE 100
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2627
Practice Address - Country:US
Practice Address - Phone:919-762-6845
Practice Address - Fax:919-762-6865
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-01519207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology