Provider Demographics
NPI:1407947526
Name:JANICKI, MARY BETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:JANICKI
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 1:1000 ASYLUM AVE
Mailing Address - Street 2:2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:860-714-8311
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4595
Practice Address - Fax:860-714-8008
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041341174400000X, 207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT041341OtherLICENSE