Provider Demographics
NPI:1679138556
Name:JANCZAK, CARISSA (OD)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:JANCZAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1664 NEIL AVE # 2138
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2333
Mailing Address - Country:US
Mailing Address - Phone:614-292-2020
Mailing Address - Fax:
Practice Address - Street 1:1664 NEIL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2333
Practice Address - Country:US
Practice Address - Phone:614-292-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.006809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist