Basic Information
| Provider Information | |||||||||
| NPI: | 1386729937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANKE | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 2530 SCRIPTURE ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762014317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9408981477 | ||||||||
| FaxNumber: | 9403824091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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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 | 208000000X | E8590 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 133527502 | 05 | TX | MEDICAID | 4074198 | 01 | TX | AETNA PIN | OTHER | 137751 | 01 | TX | PHCS PIN | OTHER | 1750369203 | 01 | GRP NPI NUMBER | OTHER | 00U87Z | 01 | TX | BCBSTX GRP PIN | OTHER | 130105100 | 01 | TX | FIRSTCARE PIN | OTHER | 2944627 | 01 | TX | CIGNA PIN | OTHER | 45183 | 01 | TX | FIRSTHEALTH PIN | OTHER | 748257 | 01 | TX | UHC PIN | OTHER | 89660Y | 01 | TX | BCBSTX IND PIN | OTHER | 140442810 | 05 | TX | MEDICAID |