1386729937 NPI number — MARILYN R JANKE MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386729937 NPI number — MARILYN R JANKE MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

JANKE

Provider First Name:

MARILYN

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1386729937

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/20/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 99371

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

FORT WORTH

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

76199-0371

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

682-885-1855

Provider Business Mailing Address Fax Number:

682-885-7347

Provider First Line Business Practice Location Address:

2530 SCRIPTURE ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

DENTON

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

76201-4317

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

940-898-1477

Provider Business Practice Location Address Fax Number:

940-382-4091

Provider Enumeration Date:

10/25/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  E8590 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 133527502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 4074198 . This is a "AETNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 137751 . This is a "PHCS PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 1750369203 . This is a "GRP NPI NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 00U87Z . This is a "BCBSTX GRP PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 130105100 . This is a "FIRSTCARE PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 2944627 . This is a "CIGNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 45183 . This is a "FIRSTHEALTH PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 748257 . This is a "UHC PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 89660Y . This is a "BCBSTX IND PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 140442810 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".