Provider Demographics
NPI:1487681805
Name:KOONTZ, DANIEL ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ALLEN
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 1:323 LEBBY ST
Mailing Address - Street 2:
Mailing Address - City:PELZER
Mailing Address - State:SC
Mailing Address - Zip Code:29669-1754
Mailing Address - Country:US
Mailing Address - Phone:864-947-6666
Mailing Address - Fax:864-947-8621
Practice Address - Street 1:323 LEBBY ST
Practice Address - Street 2:
Practice Address - City:PELZER
Practice Address - State:SC
Practice Address - Zip Code:29669-1754
Practice Address - Country:US
Practice Address - Phone:864-947-6666
Practice Address - Fax:864-947-8621
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01072951OtherRR MEDICARE
SC114290Medicaid
SC570804286OtherFEDERAL TAX ID
SC060035928OtherMEDICARE RAILROAD
GA003111796AMedicaid
GA003111796AMedicaid
SCAA72027043Medicare PIN
SC570804286OtherFEDERAL TAX ID