Provider Demographics
NPI:1558384677
Name:DAVID W KOONTZ DO INC
Entity Type:Organization
Organization Name:DAVID W KOONTZ DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:KOONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-788-9633
Mailing Address - Street 1:30 MESSIMER DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1525
Mailing Address - Country:US
Mailing Address - Phone:740-788-9633
Mailing Address - Fax:740-788-9649
Practice Address - Street 1:30 MESSIMER DRIVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1525
Practice Address - Country:US
Practice Address - Phone:740-788-9633
Practice Address - Fax:740-788-9649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHK34004321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0747204Medicaid
OH0747204Medicaid
E58890Medicare UPIN