Provider Demographics
NPI:1588685291
Name:JANIEC, JERRY (PA C)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:JANIEC
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:JANIEC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-392-5633
Practice Address - Fax:352-392-8725
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA17162080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S78471Medicare UPIN
FLE2438Medicare ID - Type Unspecified
FLE2438ZMedicare PIN