Provider Demographics
NPI:1801461793
Name:IDZAKOVICH, JOHN GERARD JR (MS, RN)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GERARD
Last Name:IDZAKOVICH
Suffix:JR
Gender:M
Credentials:MS, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:730 THURBER DR W APT H
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1209
Mailing Address - Country:US
Mailing Address - Phone:937-572-8847
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0029344363L00000X
OHRN.446630163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive CareGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty