Healthcare Provider Details

I. General information

NPI: 1255727426
Provider Name (Legal Business Name): JONATHAN ALLAN JANICZEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3188 BELLEVUE AVE
CINCINNATI OH
45219-2369
US

IV. Provider business mailing address

234 GOODMAN ST ML 665X
CINCINNATI OH
45219-2364
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8000
  • Fax: 513-584-0468
Mailing address:
  • Phone: 513-584-7425
  • Fax: 513-584-7681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.136418
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35136418
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: