Healthcare Provider Details

I. General information

NPI: 1215179254
Provider Name (Legal Business Name): ROBERT DOUGLAS JANKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 11/07/2020
Certification Date: 11/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 WILLOW OAKS CORPORATE DR # 4-420
FAIRFAX VA
22031-4512
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-7560
  • Fax: 703-204-9001
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301085030
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301085030
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101255421
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: