Healthcare Provider Details

I. General information

NPI: 1912912718
Provider Name (Legal Business Name): TIMOTHY CHARLES JANKOWSKI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16450 BOLSA CHICA ST
HUNTINGTON BEACH CA
92649-2603
US

IV. Provider business mailing address

16450 BOLSA CHICA STREET
HUNTINGTON BEACH CA
92649-2603
US

V. Phone/Fax

Practice location:
  • Phone: 714-840-1366
  • Fax: 714-846-9415
Mailing address:
  • Phone: 714-840-1366
  • Fax: 714-846-9415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number6966T
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6966T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: