Provider Demographics
NPI:1780768333
Name:MANCHESKI, JANSON A (OD)
Entity type:Individual
Prefix:
First Name:JANSON
Middle Name:A
Last Name:MANCHESKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 E GREEN BAY ST
Mailing Address - Street 2:JANSON MANCHESKI OD
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2208
Mailing Address - Country:US
Mailing Address - Phone:715-526-2376
Mailing Address - Fax:715-526-9561
Practice Address - Street 1:1244 E GREEN BAY ST
Practice Address - Street 2:JANSON MANCHESKI OD
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2208
Practice Address - Country:US
Practice Address - Phone:715-526-2376
Practice Address - Fax:715-526-9561
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI1750152W00000X
WI1750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T62675Medicare UPIN