Provider Demographics
NPI:1417921453
Name:KOELLIKER, PAUL D (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:KOELLIKER
Suffix:
Gender:M
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:PO BOX 1229
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-1229
Mailing Address - Country:US
Mailing Address - Phone:970-728-3848
Mailing Address - Fax:505-564-3755
Practice Address - Street 1:500 W PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435-1229
Practice Address - Country:US
Practice Address - Phone:970-728-3848
Practice Address - Fax:505-324-2259
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-235207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53052561Medicaid
NM53052561Medicaid