Provider Demographics
NPI:1376696708
Name:KOESTER, AMBER LEIGH (OD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEIGH
Last Name:KOESTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:17249 CHESTERFIELD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1423
Practice Address - Country:US
Practice Address - Phone:636-787-7000
Practice Address - Fax:636-787-0100
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2952152W00000X
MO2002015313152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1376696708Medicaid
MOMA5227033Medicare UPIN
MOU90342Medicare UPIN
MO1376696708Medicaid