Provider Demographics
NPI:1063589133
Name:KUNDRAT, JOHN STEPHEN (MD PA)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:KUNDRAT
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 FOURTH STREET
Mailing Address - Street 2:BLDG 3
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4405
Mailing Address - Country:US
Mailing Address - Phone:208-746-0458
Mailing Address - Fax:208-743-6020
Practice Address - Street 1:3316 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4405
Practice Address - Country:US
Practice Address - Phone:208-746-0458
Practice Address - Fax:208-743-6020
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3432207W00000X
WAMD00014874207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002460100Medicaid
WA1478601OtherMEDICAID
A42611Medicare UPIN
ID1110827Medicare ID - Type Unspecified