=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972533404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES JANOUSEK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 03/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 PINEWOOD WAY SW
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32064-4054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-364-4101
-----------------------------------------------------
Fax | 386-364-5145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 PINEWOOD WAY SW
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-364-4101
-----------------------------------------------------
Fax | 386-364-5145
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 0030682
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------