MEDICARE: DR. JOHN MARTIN LASAK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0901X	Otology & Neurotology Physician	04-29030	KS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	040016259	OTHER	KS	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	412510	OTHER	KS	FIRSTGAURD
2	9633	OTHER	KS	PHS-PPK
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	100888	OTHER	KS	BLUE CROSS
6	48118525067206A003	OTHER	KS	CHAMPUS

General Provider Information

NPI Number	:	1710989082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN MARTIN LASAK M.D.

Provider Business Mailing Address
First Line	:	9350 E CENTRAL AVE
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67206-4999
Country	:	US
Telephone Number	:	316-686-6608
Fax Number	:	316-686-3624

Provider Business Practice Location Address
First Line	:	9350 E CENTRAL AVE
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67206-2555
Country	:	US
Telephone Number	:	316-686-6608
Fax Number	:	316-686-3624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	11/23/2022

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Directions to “ DR. JOHN MARTIN LASAK M.D.” Practice Location

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