Provider Demographics
NPI:1538169941
Name:KLOSAK, JOHN J (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:KLOSAK
Suffix:
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 1:2101 NICHOLAS CT
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-2177
Mailing Address - Country:US
Mailing Address - Phone:563-650-7355
Mailing Address - Fax:
Practice Address - Street 1:2101 NICHOLAS CT
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-2177
Practice Address - Country:US
Practice Address - Phone:563-650-7355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA283752086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA28375OtherLICENSE
IL036060710Medicaid
IA2076505Medicaid
IA03159Medicare ID - Type Unspecified