Provider Demographics
NPI:1437145018
Name:KOONCE, ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:KOONCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RANDOLPH RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1122
Mailing Address - Country:US
Mailing Address - Phone:704-384-9103
Mailing Address - Fax:704-316-0508
Practice Address - Street 1:2600 E 7TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4375
Practice Address - Country:US
Practice Address - Phone:704-384-8800
Practice Address - Fax:704-384-8819
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34063208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8950023Medicaid
NCA98977Medicare UPIN
NC2178596AMedicare ID - Type Unspecified