Provider Demographics
NPI:1659832640
Name:KOONTZ, LAKEN (DO)
Entity type:Individual
Prefix:
First Name:LAKEN
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 KENT PL
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-1947
Practice Address - Country:US
Practice Address - Phone:865-238-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN0000004706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ105475Medicaid