Healthcare Provider Details

I. General information

NPI: 1568532562
Provider Name (Legal Business Name): JOHN KENNETH KOSIK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HCR 61 BOX 30 JCT US HWY 160 & NR 35 - RED MESA
TEEC NOS POS AZ
86514
US

IV. Provider business mailing address

HCR 61 BOX 30 JCT US HWY 160 & NR 35 - RED MESA
TEEC NOS POS AZ
86514
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5000
  • Fax: 928-656-5164
Mailing address:
  • Phone: 928-656-5000
  • Fax: 928-656-5164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5766873-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: