Provider Demographics
NPI:1073575023
Name:KOEHLER, RICHARD HENRY (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:HENRY
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 CHADSWORTH LANE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461
Mailing Address - Country:US
Mailing Address - Phone:315-440-5507
Mailing Address - Fax:315-452-2510
Practice Address - Street 1:510 SOUTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-592-3510
Practice Address - Fax:315-452-2510
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144511207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02357486Medicaid
NY1073575023Medicaid
NY1073575023OtherBCBS
NY1073575023Medicaid
NYC66516Medicare UPIN
NYJ400003639Medicare PIN