Provider Demographics
NPI:1053038877
Name:MISOCKY, JOHN DONIVON
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DONIVON
Last Name:MISOCKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-4361
Mailing Address - Country:US
Mailing Address - Phone:937-346-7330
Mailing Address - Fax:
Practice Address - Street 1:2537 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-4361
Practice Address - Country:US
Practice Address - Phone:937-346-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0464184Medicaid