Provider Demographics
NPI:1225108160
Name:KOONTZ, STEPHANIE LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LOUISE
Last Name:KOONTZ
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 1:40 HOLLAND STREET
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144
Mailing Address - Country:US
Mailing Address - Phone:617-629-6330
Mailing Address - Fax:617-629-6128
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6330
Practice Address - Fax:617-629-6128
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220863207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2086115Medicaid
MAA37584Medicare PIN