Provider Demographics
NPI:1104920511
Name:KOSKO, JOHN WESLEY JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
Last Name:KOSKO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5112
Mailing Address - Country:US
Mailing Address - Phone:218-333-5000
Mailing Address - Fax:
Practice Address - Street 1:1233 34TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5112
Practice Address - Country:US
Practice Address - Phone:218-333-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50675208800000X
KS26795208800000X
AZ33311208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100282080AMedicaid
MN340000979Medicare PIN
B54288Medicare UPIN
KS059311Medicare ID - Type Unspecified