Provider Demographics
NPI:1730350695
Name:STEPHAN JANKOWSKI, O.D.
Entity type:Organization
Organization Name:STEPHAN JANKOWSKI, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:JANKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-648-2456
Mailing Address - Street 1:93 S MORSE ST
Mailing Address - Street 2:PO BOX 208
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471-1364
Mailing Address - Country:US
Mailing Address - Phone:810-648-2456
Mailing Address - Fax:810-648-5279
Practice Address - Street 1:93 S MORSE ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1364
Practice Address - Country:US
Practice Address - Phone:810-648-2456
Practice Address - Fax:810-648-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002858332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
T33598Medicare UPIN
MI0327060001Medicare NSC
MI0G66508Medicare Oscar/Certification