Provider Demographics
NPI:1194708644
Name:JANUSONIS, PALMIRA A (MD)
Entity type:Individual
Prefix:DR
First Name:PALMIRA
Middle Name:A
Last Name:JANUSONIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4266
Mailing Address - Country:US
Mailing Address - Phone:262-787-4026
Mailing Address - Fax:
Practice Address - Street 1:791 E SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3844
Practice Address - Country:US
Practice Address - Phone:262-569-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2009-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16079-020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31223900Medicaid
P00606645OtherRAIL ROAD MEDICARE
WI0031-68625Medicare PIN
WIB53837Medicare UPIN
WI0004-68710Medicare ID - Type UnspecifiedPROVIDER NUMBER
WI31223900Medicaid