Provider Demographics
NPI:1013196864
Name:KALISVAART, JONATHAN FRANK (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:FRANK
Last Name:KALISVAART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-624-3126
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93105208800000X
GA0622322088P0231X
WAMD 602070552088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA127902334AMedicaid
WABK9574458OtherDEA