Provider Demographics
NPI:1710627617
Name:RUNNELS, JACK EDWARD (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:RUNNELS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5651 POPLAR TENT RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-7686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5651 POPLAR TENT RD STE 102
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-7686
Practice Address - Country:US
Practice Address - Phone:704-782-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2025-01850207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine