Provider Demographics
NPI:1508066721
Name:KOOS, STEPHANIE R (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:KOOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:312 9TH ST SW
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2929
Mailing Address - Country:US
Mailing Address - Phone:319-352-4340
Mailing Address - Fax:319-352-0745
Practice Address - Street 1:312 9TH ST SW
Practice Address - Street 2:SUITE 1200
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2929
Practice Address - Country:US
Practice Address - Phone:319-352-4340
Practice Address - Fax:319-352-0745
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8116207Q00000X
IA3923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508066721Medicaid
IA719260195Medicare PIN