Provider Demographics
NPI:1104857978
Name:KOEHLER, RONALD (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:KOEHLER
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 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:4175 N EUCLID AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2483
Practice Address - Country:US
Practice Address - Phone:989-667-0491
Practice Address - Fax:989-667-0493
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRK07099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P43930OtherMEDICARE GROUP
RK007099OtherBCBS
MI0Z96017OtherMEDICARE PTAN
MI5176034Medicaid
MI0E66019OtherMEDICARE GROUP
MI1786080Medicaid
MIP43930005Medicare PIN
MIZ96017029Medicare PIN
MIE26611Medicare ID - Type Unspecified
MI0Z96017OtherMEDICARE PTAN
MIE26611Medicare UPIN
MIE66019028Medicare PIN