Provider Demographics
NPI:1700845211
Name:KOONTZ, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
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 1:4250 ALLISTAIR RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1204
Mailing Address - Country:US
Mailing Address - Phone:336-768-0196
Mailing Address - Fax:336-765-0430
Practice Address - Street 1:2915 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4005
Practice Address - Country:US
Practice Address - Phone:336-765-5221
Practice Address - Fax:336-765-0430
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15108208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8950063Medicaid
NC15108OtherNC LICENSE
NCAK5554630OtherDEA NUMBER
NC15108OtherNC LICENSE
NC207958AMedicare ID - Type Unspecified