Provider Demographics
NPI:1144751256
Name:KOEHLER, MAYA ITZA (MD)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:ITZA
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 N WINCHESTER AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4356
Mailing Address - Country:US
Mailing Address - Phone:937-631-2393
Mailing Address - Fax:
Practice Address - Street 1:521 E MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3865
Practice Address - Country:US
Practice Address - Phone:509-962-1414
Practice Address - Fax:509-452-5224
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12158207Q00000X
IL036154635207Q00000X
ORMD203985207Q00000X
WAMD61335254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2221896Medicaid
WA0460399OtherLABOR AND INDUSTRIES