Provider Demographics
NPI:1013914035
Name:KORNICKI, JANUSZ S (MD)
Entity Type:Individual
Prefix:DR
First Name:JANUSZ
Middle Name:S
Last Name:KORNICKI
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 1:1130 RARITAN RD
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-3328
Mailing Address - Country:US
Mailing Address - Phone:908-276-6644
Mailing Address - Fax:908-276-3862
Practice Address - Street 1:1130 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-3328
Practice Address - Country:US
Practice Address - Phone:908-276-6644
Practice Address - Fax:908-276-3862
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04135100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6209203Medicaid
449772Medicare ID - Type Unspecified
D20062Medicare UPIN