Provider Demographics
NPI:1871693176
Name:JANIK, GRACE M (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:M
Last Name:JANIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 E NEWPORT AVE
Mailing Address - Street 2:SUITE 707
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2984
Mailing Address - Country:US
Mailing Address - Phone:414-289-9668
Mailing Address - Fax:414-289-0498
Practice Address - Street 1:2315 N LAKE DR
Practice Address - Street 2:SUITE 501
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4518
Practice Address - Country:US
Practice Address - Phone:414-289-9668
Practice Address - Fax:414-289-0498
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27674-020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391345728029OtherANTHEM BLUE CROSS BLUE SH
WIE30362Medicare UPIN