Healthcare Provider Details

I. General information

NPI: 1982604930
Provider Name (Legal Business Name): JAN F ONIK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 01/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 3RD ST
LOUISIANA MO
63353-2000
US

IV. Provider business mailing address

211 S 3RD ST
LOUISIANA MO
63353-2000
US

V. Phone/Fax

Practice location:
  • Phone: 573-754-5555
  • Fax: 573-754-4077
Mailing address:
  • Phone: 573-754-5555
  • Fax: 573-754-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR5C36
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: