Provider Demographics
NPI:1093767881
Name:KOETS, JEFFREY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:KOETS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 S US-27
Mailing Address - Street 2:SUITE #7
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820
Mailing Address - Country:US
Mailing Address - Phone:517-669-4411
Mailing Address - Fax:
Practice Address - Street 1:12900 S US-27
Practice Address - Street 2:SUITE #7
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820
Practice Address - Country:US
Practice Address - Phone:517-669-4411
Practice Address - Fax:517-669-4433
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN236930146Medicare PIN
U82319Medicare UPIN
ON66730002Medicare ID - Type Unspecified
MI1272120001Medicare NSC