Provider Demographics
NPI:1558598185
Name:KOONTZ, WHEALEN MOFFIT (MD)
Entity Type:Individual
Prefix:DR
First Name:WHEALEN
Middle Name:MOFFIT
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 1:193 SEDGEFORD SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:193 SEDGEFORD SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-1716
Practice Address - Country:US
Practice Address - Phone:319-365-8597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine