Provider Demographics
NPI:1538132840
Name:KOSAREK, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:KOSAREK
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 5338
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708
Mailing Address - Country:US
Mailing Address - Phone:254-202-4660
Mailing Address - Fax:254-202-4716
Practice Address - Street 1:201 OLD HEWITT RD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-202-7700
Practice Address - Fax:254-202-7710
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115231603Medicaid
TX80Y505OtherBCBS
B24087Medicare UPIN
TX80Y505Medicare ID - Type Unspecified
TX115231603Medicaid
080119985Medicare PIN