Basic Information
| Provider Information | |||||||||
| NPI: | 1053610808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANUSZEWSKI | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 S HARBOR CITY BLVD STE 610 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217237716 | ||||||||
| FaxNumber: | 3217230604 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 S HARBOR CITY BLVD STE 610 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217237716 | ||||||||
| FaxNumber: | 3217230604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2011 | ||||||||
| LastUpdateDate: | 01/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | OS14529 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1143045 | 01 | FL | CAREPLUS | OTHER | 9076362 | 01 | FL | CIGNA | OTHER | 4762182 | 01 | FL | AETNA | OTHER | 021089200 | 05 | FL | MEDICAID | 1531493 | 01 | FL | WELLCARE | OTHER | W9TNA | 01 | FL | FLORIDA BLUE | OTHER |