Provider Demographics
NPI:1558325860
Name:KVASNICKA, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:KVASNICKA
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 1:1575 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1126
Mailing Address - Country:US
Mailing Address - Phone:651-232-7348
Mailing Address - Fax:651-232-6665
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-232-7348
Practice Address - Fax:651-232-6665
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31548207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND81066Medicare UPIN