Basic Information
| Provider Information | |||||||||
| NPI: | 1386655389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANJUCK | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3687 MT DIABLO BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945493717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259626602 | ||||||||
| FaxNumber: | 9252996849 | ||||||||
| Practice Location | |||||||||
| Address1: | 3687 MT DIABLO BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945493717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259626602 | ||||||||
| FaxNumber: | 9252996849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | G72767 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G727670 | 05 | CA | MEDICAID |