Basic Information
| Provider Information | |||||||||
| NPI: | 1013196864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALISVAART | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | FRANK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 8TH AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096243126 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A93105 | CA | N | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 062232 | GA | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 2088P0231X | MD 60207055 | WA | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 127902334A | 05 | WA | MEDICAID | BK9574458 | 01 | WA | DEA | OTHER |