Provider Demographics
NPI:1609189240
Name:JANICKI, MARCUS MATTHEW (DO)
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:MATTHEW
Last Name:JANICKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3030 NORTH ROCKY POINT DRIVE WEST
Mailing Address - Street 2:SUITE 670
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5906
Mailing Address - Country:US
Mailing Address - Phone:813-289-6597
Mailing Address - Fax:813-289-6592
Practice Address - Street 1:3030 NORTH ROCKY POINT DRIVE WEST
Practice Address - Street 2:SUITE 670
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5906
Practice Address - Country:US
Practice Address - Phone:813-289-6597
Practice Address - Fax:813-289-6592
Is Sole Proprietor?:No
Enumeration Date:2010-07-25
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALDO.1240207Q00000X, 208M00000X
FLOS12477207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL134283Medicaid
AL102I081347Medicare PIN