Provider Demographics
NPI:1639106289
Name:JANOTKA, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:JANOTKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 CAMBERLEY LN
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-5113
Mailing Address - Country:US
Mailing Address - Phone:727-286-6531
Mailing Address - Fax:
Practice Address - Street 1:707 OLD DALTON ELLIJAY RD
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2029
Practice Address - Country:US
Practice Address - Phone:706-517-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29748207PE0004X
GA70155207PE0004X
FLME 107308207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61400002OtherBLUECROSS PROVIDER NUMBER
GA70155OtherMEDICAL LICENSE
FLME 107308OtherMEDICAL LICENSE
MD142257Y1ZMedicare PIN
GA70155OtherMEDICAL LICENSE
FLME 107308OtherMEDICAL LICENSE