Provider Demographics
NPI:1336102086
Name:DEXTER D KOONS MD PC
Entity Type:Organization
Organization Name:DEXTER D KOONS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEXTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-296-6872
Mailing Address - Street 1:PO BOX 8561
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-8561
Mailing Address - Country:US
Mailing Address - Phone:719-320-3515
Mailing Address - Fax:719-543-1309
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-320-3515
Practice Address - Fax:719-543-1309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04013876Medicaid
COC419308Medicare PIN