Provider Demographics
NPI:1215999891
Name:JANETZKO, EDGAR (MD)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:
Last Name:JANETZKO
Suffix:
Gender:M
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:1960 N DATE ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3701
Practice Address - Country:US
Practice Address - Phone:575-894-7662
Practice Address - Fax:575-894-7930
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1895207R00000X
NM96-286207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1447278-01Medicaid
TX1447278-01Medicaid
TX00398QMedicare ID - Type Unspecified