Healthcare Provider Details

I. General information

NPI: 1710989082
Provider Name (Legal Business Name): JOHN MARTIN LASAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 E CENTRAL AVE
WICHITA KS
67206-2555
US

IV. Provider business mailing address

9350 E CENTRAL AVE
WICHITA KS
67206-4999
US

V. Phone/Fax

Practice location:
  • Phone: 316-686-6608
  • Fax: 316-686-3624
Mailing address:
  • Phone: 316-686-6608
  • Fax: 316-686-3624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number04-29030
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: