Provider Demographics
NPI:1306380092
Name:JOHN W. KOETT, M.D., PHD, INC.
Entity Type:Organization
Organization Name:JOHN W. KOETT, M.D., PHD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:KOETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:951-486-5255
Mailing Address - Street 1:11730 JOYAS CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2817
Mailing Address - Country:US
Mailing Address - Phone:951-486-5255
Mailing Address - Fax:951-486-5270
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-5255
Practice Address - Fax:951-486-5270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty