Provider Demographics
NPI:1467561019
Name:KOETTER, PAUL (MPT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:KOETTER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W RALPH HALL PKWY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6658
Mailing Address - Country:US
Mailing Address - Phone:972-771-9081
Mailing Address - Fax:
Practice Address - Street 1:1005 W RALPH HALL PKWY
Practice Address - Street 2:SUITE 207
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6658
Practice Address - Country:US
Practice Address - Phone:972-772-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1173470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1103332OtherLICENSE #
TX1173470OtherTEXAS LICENSE