Provider Demographics
NPI:1538186127
Name:JANICK, JOHN J (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:JANICK
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 1:1649 TAMIAMI TRL UNIT 1C
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1019
Mailing Address - Country:US
Mailing Address - Phone:941-629-3366
Mailing Address - Fax:941-629-6999
Practice Address - Street 1:1649 TAMIAMI TRL UNIT 1C
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1019
Practice Address - Country:US
Practice Address - Phone:941-629-3366
Practice Address - Fax:941-629-6999
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027204174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD82558Medicare UPIN