Basic Information
| Provider Information | |||||||||
| NPI: | 1013906247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACHOWIAK | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27476 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794309410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067433150 | ||||||||
| FaxNumber: | 8067433168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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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 | 207R00000X | K3013 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 86E875 | 01 | TX | BC/BS | OTHER | 124624100 | 05 | TX | MEDICAID | A159 | 01 | NM | TRIWEST | OTHER | 100154530A | 05 | OK | MEDICAID | 105159102 | 05 | TX | MEDICAID | 124624101 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 68857 | 05 | NM | MEDICAID | 80853Z | 01 | TX | HMO BLUE | OTHER | 105159101 | 05 | TX | MEDICAID | Q5263 | 05 | NM | MEDICAID | 68857 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER |