Provider Demographics
NPI:1144207366
Name:KOEHLER, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KOEHLER
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 1:1840 ELDRON BLVD SE STE 1
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6871
Mailing Address - Country:US
Mailing Address - Phone:321-312-4580
Mailing Address - Fax:321-914-4053
Practice Address - Street 1:1840 ELDRON BLVD SE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6871
Practice Address - Country:US
Practice Address - Phone:321-312-4580
Practice Address - Fax:321-914-4053
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36072658207PT0002X
FLME133563207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL769380 - L04591Medicare PIN
ILC43207Medicare UPIN