Provider Demographics
NPI:1962592469
Name:KOKOSKA, EVAN R (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:KOKOSKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2001 W 86TH ST
Mailing Address - Street 2:PEDIATRIC HOSPITAL
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1902
Mailing Address - Country:US
Mailing Address - Phone:317-338-8857
Mailing Address - Fax:317-338-8858
Practice Address - Street 1:2001 W. 86TH STREET
Practice Address - Street 2:PEDIATRIC HOSPITAL
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-338-8857
Practice Address - Fax:317-338-8858
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01053703A2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150489001Medicaid
G40713Medicare UPIN
5M684Medicare PIN