Provider Demographics
NPI:1689613093
Name:KOONTZ, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:8000 W 110TH ST
Mailing Address - Street 2:STE 150
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2382
Mailing Address - Country:US
Mailing Address - Phone:913-599-6777
Mailing Address - Fax:913-599-3955
Practice Address - Street 1:1000 CARONDELET DR
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4673
Practice Address - Country:US
Practice Address - Phone:913-599-6777
Practice Address - Fax:913-599-3955
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3M472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
16332035OtherBCBS PROVIDER NUMBER
KS100126630BMedicaid
MO203305107Medicaid
E65921Medicare UPIN
16332035OtherBCBS PROVIDER NUMBER