Provider Demographics
NPI:1194764373
Name:JANCZAK, RICHARD MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MATTHEW
Last Name:JANCZAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:M
Other - Last Name:JANCZAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3154 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-3222
Mailing Address - Country:US
Mailing Address - Phone:614-875-0011
Mailing Address - Fax:614-875-0736
Practice Address - Street 1:3154 PARK ST
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-3222
Practice Address - Country:US
Practice Address - Phone:614-875-0011
Practice Address - Fax:614-875-0736
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.048495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0587048Medicaid
OH0587048Medicaid
OH000000019329OtherANTHEM BC/BS
A15972Medicare UPIN
OH0587048Medicaid