Basic Information
| Provider Information | |||||||||
| NPI: | 1538132840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSAREK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5338 | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542024660 | ||||||||
| FaxNumber: | 2542024716 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 OLD HEWITT RD | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542027700 | ||||||||
| FaxNumber: | 2542027710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G5265 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 115231603 | 05 | TX | MEDICAID | 80Y505 | 01 | TX | BCBS | OTHER |