Provider Demographics
NPI:1629019476
Name:JANICIK, REGINA WAGNER (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINA
Middle Name:WAGNER
Last Name:JANICIK
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 1:80 MAIDEN LN RM 1902
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4773
Mailing Address - Country:US
Mailing Address - Phone:212-379-6480
Mailing Address - Fax:
Practice Address - Street 1:80 MAIDEN LN RM 1901
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4717
Practice Address - Country:US
Practice Address - Phone:212-379-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214138207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H40137Medicare UPIN