Provider Demographics
NPI:1598741837
Name:KOOISTRA, CAROL A (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:KOOISTRA
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 1:541 FLOYD RD
Mailing Address - Street 2:541 FLOYD ROAD
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1520
Mailing Address - Country:US
Mailing Address - Phone:864-585-6179
Mailing Address - Fax:864-583-5403
Practice Address - Street 1:541 FLOYD RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1520
Practice Address - Country:US
Practice Address - Phone:864-585-6179
Practice Address - Fax:864-583-5403
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC133492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135C9Medicaid
NCB91448OtherUPIN
135C9OtherBCBS
NCP00316714OtherMEDICARE RR
NC89135C9Medicaid