Provider Demographics
NPI:1205813524
Name:JANKOWSKI, STEPHAN CARL (OD)
Entity Type:Individual
Prefix:MR
First Name:STEPHAN
Middle Name:CARL
Last Name:JANKOWSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471-0208
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:48471-0208
Practice Address - Country:US
Practice Address - Phone:810-648-2456
Practice Address - Fax:810-648-5279
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002858152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T33598Medicare UPIN
MI0327060001Medicare NSC
MIOG66508Medicare ID - Type Unspecified