1003822016 NPI number — JOHN D MESKO M.D.

Table of content: JOHN D MESKO M.D. (NPI 1003822016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003822016 NPI number — JOHN D MESKO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MESKO
Provider First Name:
JOHN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003822016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
403 NORTH MORROW
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MENA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-394-4595
Provider Business Mailing Address Fax Number:
479-394-1140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 NORTH MORROW
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MENA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-394-4595
Provider Business Practice Location Address Fax Number:
479-394-1140
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  C6220 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100071960 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112972001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50764 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 710709244 . This is a "TAX ID #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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