Provider Demographics
NPI:1437228152
Name:KOONTZ, PAUL WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:WILLIAM
Last Name:KOONTZ
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 1:1000 E PRIMROSE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5178
Mailing Address - Country:US
Mailing Address - Phone:417-269-4646
Mailing Address - Fax:
Practice Address - Street 1:1000 E PRIMROSE ST STE 550
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5180
Practice Address - Country:US
Practice Address - Phone:417-269-4647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002028070207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO159012OtherBLUECROSS BLUESHIELD
MO159012OtherBLUECROSS BLUESHIELD