Provider Demographics
NPI:1255678546
Name:JOHN S KUNDRAT, MD PA
Entity Type:Organization
Organization Name:JOHN S KUNDRAT, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KUNDRAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-746-0458
Mailing Address - Street 1:3316 4TH ST
Mailing Address - Street 2:BLDG 3
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4405
Mailing Address - Country:US
Mailing Address - Phone:208-746-0458
Mailing Address - Fax:208-743-6020
Practice Address - Street 1:3316 4TH ST
Practice Address - Street 2:BLDG 3
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4405
Practice Address - Country:US
Practice Address - Phone:208-746-0458
Practice Address - Fax:208-743-6020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3432207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002460100Medicaid
WA1478601Medicaid
1110827Medicare PIN
A42611Medicare UPIN