Provider Demographics
NPI:1619086626
Name:KRISKOVICH, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:KRISKOVICH
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 1:100 W 4TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2448
Mailing Address - Country:US
Mailing Address - Phone:931-528-1575
Mailing Address - Fax:931-526-2962
Practice Address - Street 1:100 W 4TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2448
Practice Address - Country:US
Practice Address - Phone:931-528-1575
Practice Address - Fax:931-526-2962
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD036079174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3872688Medicaid
TN3872688Medicaid
TN3872688Medicare ID - Type Unspecified