Provider Demographics
NPI:1740270792
Name:ANDRESHAK, JOHN L (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:ANDRESHAK
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 1:250 HOSPITAL PL
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7559
Mailing Address - Country:US
Mailing Address - Phone:907-714-5770
Mailing Address - Fax:907-714-3111
Practice Address - Street 1:240 HOSPITAL PL STE 104
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7559
Practice Address - Country:US
Practice Address - Phone:907-714-5770
Practice Address - Fax:907-714-3111
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087072207XS0117X
AKMEDS6826207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01141220OtherMEDICARE RR
ILG29796Medicare UPIN
IL206147164Medicare PIN