Provider Demographics
NPI:1609010156
Name:KOONTZ, THADEUS B (MD)
Entity Type:Individual
Prefix:
First Name:THADEUS
Middle Name:B
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-2175
Mailing Address - Fax:208-376-0285
Practice Address - Street 1:428 6TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2355
Practice Address - Country:US
Practice Address - Phone:208-750-7462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM119842084P0800X
IDM-119842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20003355Medicare PIN