Provider Demographics
NPI:1063456218
Name:KOOYER, KURT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:WILLIAM
Last Name:KOOYER
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 1:641 COTTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2829 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6050
Practice Address - Country:US
Practice Address - Phone:701-232-9000
Practice Address - Fax:701-893-9057
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9202207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12025Medicaid
NDF88962Medicare UPIN
ND22282Medicare ID - Type Unspecified