Provider Demographics
NPI:1568532562
Name:KOSIK, JOHN KENNETH (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENNETH
Last Name:KOSIK
Suffix:
Gender:M
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:HCR 61 BOX 30
Mailing Address - Street 2:JCT US HWY 160 & NR 35 - RED MESA
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:928-656-5164
Practice Address - Street 1:HCR 61 BOX 30
Practice Address - Street 2:JCT US HWY 160 & NR 35 - RED MESA
Practice Address - City:TEEC NOS POS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:928-656-5164
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5766873-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ260813Medicaid
NM36250767Medicaid
CO40584054Medicaid
AZ260813Medicaid