Provider Demographics
NPI:1487645370
Name:KOOYMAN, MICHAEL (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KOOYMAN
Suffix:
Gender:M
Credentials:DPM
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-565-6641
Mailing Address - Fax:702-565-9249
Practice Address - Street 1:2649 W HORIZON RIDGE PKWY
Practice Address - Street 2:100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4801
Practice Address - Country:US
Practice Address - Phone:702-565-6641
Practice Address - Fax:702-565-9249
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0503213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1487645370Medicaid
NV100512730Medicaid
NV105426Medicare PIN
NV105369Medicare PIN