Provider Demographics
NPI:1538499454
Name:DILAN-KOETJE, JEANETTE (DO)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:DILAN-KOETJE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:573-348-8000
Mailing Address - Fax:
Practice Address - Street 1:304A E 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1808
Practice Address - Country:US
Practice Address - Phone:573-392-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-13447207P00000X
FLOS13778207P00000X
MO2023032035207R00000X
MS226611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty