Provider Demographics
NPI:1386817104
Name:KOONTZ, JASON (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 STERLING RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3919 STERLING RIDGE LN
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5459
Practice Address - Country:US
Practice Address - Phone:919-970-6452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-13
Last Update Date:2008-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110495207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease