Provider Demographics
NPI:1740261957
Name:JANICKI, PETER THOMAS (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:THOMAS
Last Name:JANICKI
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 1:7508 MOUNT VERNON DR
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6924
Mailing Address - Country:US
Mailing Address - Phone:817-498-8944
Mailing Address - Fax:817-355-4511
Practice Address - Street 1:1615 HOSPITAL PKWY
Practice Address - Street 2:STE. 210
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-5934
Practice Address - Country:US
Practice Address - Phone:817-540-3121
Practice Address - Fax:817-355-4511
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1970174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85720JMedicare ID - Type Unspecified
TXE77926Medicare UPIN