Provider Demographics
NPI:1104823327
Name:KRISKA, JAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:
Last Name:KRISKA
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 249
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-0249
Mailing Address - Country:US
Mailing Address - Phone:336-679-4963
Mailing Address - Fax:336-679-2549
Practice Address - Street 1:905 ROCKFORD ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5323
Practice Address - Country:US
Practice Address - Phone:336-719-2440
Practice Address - Fax:336-719-6915
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701018207R00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1055XOtherBCBS OF NC
NC110153703OtherRAILROAD MEDICARE
NC1789230OtherUNITED HEALTHCARE
NC111395OtherCIGNA
NC20412OtherPARTNERS MEDICARE
NC890155XMedicaid
NC001011966003OtherONE HEALTH/GREAT WEST
NC75844OtherMEDCOST
NC277869OtherMAMSI
NC5892546OtherAETNA
NC142031OtherSOUTHCARE PPO
NC253533OtherTRIGON BCBS OF VA
NC2237859Medicare PIN
NC277869OtherMAMSI