Provider Demographics
NPI:1619962768
Name:KOEHN, GERARD G (MD)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:G
Last Name:KOEHN
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 1:595 CHAPEL HILLS DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1022
Mailing Address - Country:US
Mailing Address - Phone:719-574-0310
Mailing Address - Fax:719-574-6574
Practice Address - Street 1:595 CHAPEL HILLS DR
Practice Address - Street 2:SUITE 303
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1022
Practice Address - Country:US
Practice Address - Phone:719-574-0310
Practice Address - Fax:719-574-6574
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01166107Medicaid
CO01166107Medicaid
CO372028Medicare PIN