Provider Demographics
NPI:1689718090
Name:JANKOWICH, MATTHEW DMITRI (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DMITRI
Last Name:JANKOWICH
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 1:55 MODENA AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-2012
Mailing Address - Country:US
Mailing Address - Phone:401-714-4894
Mailing Address - Fax:
Practice Address - Street 1:830 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4734
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214099207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJA A35826Medicare ID - Type UnspecifiedPARTICIPATING PROVIDER