Provider Demographics
NPI:1649229345
Name:KOOISTRA, JON B (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:B
Last Name:KOOISTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J. BRENT
Other - Middle Name:
Other - Last Name:KOOISTRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:752 N HIGH POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2236
Mailing Address - Country:US
Mailing Address - Phone:608-824-4000
Mailing Address - Fax:608-824-4910
Practice Address - Street 1:752 N HIGH POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2236
Practice Address - Country:US
Practice Address - Phone:608-824-4000
Practice Address - Fax:608-824-4910
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18484-020207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1175OtherDEAN HEALTH INSURANCE
WI31012500Medicaid
WI030002304Medicare PIN
WI021674150Medicare PIN
WIB54273Medicare UPIN
WI016954340Medicare PIN