Provider Demographics
NPI:1093830598
Name:KOHTZ, STEVEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:A
Last Name:KOHTZ
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:730 N COLLEGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3382
Practice Address - Country:US
Practice Address - Phone:208-814-7300
Practice Address - Fax:208-933-4601
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808045500Medicaid
IDP00654625OtherMCRR
ID1100384Medicare PIN