Provider Demographics
NPI:1568453272
Name:KOITA, MUNIRA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MUNIRA
Middle Name:M
Last Name:KOITA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126
Mailing Address - Country:US
Mailing Address - Phone:561-809-9700
Mailing Address - Fax:248-788-0462
Practice Address - Street 1:205 E BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:561-809-9700
Practice Address - Fax:248-788-0462
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400307716OtherFPN MEDICARE PTAN
MIF25662Medicare UPIN