Provider Demographics
NPI:1447257316
Name:KIVISTO, ERIC A (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:KIVISTO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-9216
Mailing Address - Country:US
Mailing Address - Phone:815-539-1789
Mailing Address - Fax:815-539-1430
Practice Address - Street 1:1405 E 12TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-9010
Practice Address - Country:US
Practice Address - Phone:815-539-1789
Practice Address - Fax:815-539-1430
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011210208600000X
IL036091073208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371342699OtherFEIN NUMBER
IL036091073Medicaid
IL02706617OtherBLUE CROSS/BLUE SHIELD
IL02706617OtherBLUE CROSS/BLUE SHIELD
IL368000Medicare ID - Type Unspecified