Provider Demographics
NPI:1619931896
Name:THANIK, JAIMALA (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIMALA
Middle Name:
Last Name:THANIK
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 1:604 ELMWOOD AVENUE
Mailing Address - Street 2:BOX 604
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-2141
Mailing Address - Fax:585-244-7271
Practice Address - Street 1:604 ELMWOOD AVENUE
Practice Address - Street 2:BOX 604
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-2141
Practice Address - Fax:585-244-7271
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121860208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102222AHOtherPREFERRED CARE
NY00362987Medicaid
NY010121860OtherBLUE CHOICE
16725BMedicare ID - Type Unspecified
NY00362987Medicaid