Provider Demographics
NPI:1770674897
Name:KOKOSKA, MIMI S (MD)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:S
Last Name:KOKOSKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 W LOOMIS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4858
Mailing Address - Country:US
Mailing Address - Phone:414-281-4466
Mailing Address - Fax:
Practice Address - Street 1:4600 W LOOMIS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4858
Practice Address - Country:US
Practice Address - Phone:414-281-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3850207YX0007X, 207YX0905X
IN01054222A207Y00000X
WI64145207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR03120016300OtherQUALCHOICE
ARP00082526OtherRAILROAD MEDICARE
ARE3850OtherTRICARE
AR150875001Medicaid
AR150875001Medicaid
AR03120016300OtherQUALCHOICE