Provider Demographics
NPI:1275549099
Name:JANIK, SUSAN BARBARA (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BARBARA
Last Name:JANIK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2181
Mailing Address - Country:US
Mailing Address - Phone:860-233-2020
Mailing Address - Fax:860-236-9004
Practice Address - Street 1:1013 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2181
Practice Address - Country:US
Practice Address - Phone:860-233-2020
Practice Address - Fax:860-236-9004
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002589152W00000X
MA4316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0336611Medicaid
CT004227147Medicaid
CT400001480OtherMEDICARE
MA410048374OtherMEDICARE RAILROAD
MAW16316OtherBLUE CROSS BLUE SHIELD
MAW16316OtherBLUE CROSS BLUE SHIELD
MAW17434Medicare ID - Type Unspecified