Provider Demographics
NPI:1396958260
Name:KOKOSZKA, MELISSA JO (MD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:JO
Last Name:KOKOSZKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E PRIMROSE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5206
Mailing Address - Country:US
Mailing Address - Phone:417-888-0167
Mailing Address - Fax:417-888-0189
Practice Address - Street 1:222 E PRIMROSE ST
Practice Address - Street 2:SUITE E
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5206
Practice Address - Country:US
Practice Address - Phone:417-888-0167
Practice Address - Fax:417-888-0189
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2016-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066112207L00000X
MO2009009429207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263OtherTRICARE WEST
MO1396958260Medicaid
P00760866OtherRAILROAD MEDICARE
AR180693001Medicaid
MD413312900Medicaid
MDR470Medicare PIN
P00760866OtherRAILROAD MEDICARE
MO132680099Medicare PIN