Provider Demographics
NPI:1790892461
Name:KOESTER, GLENN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ALAN
Last Name:KOESTER
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 1:3863 S. BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034
Mailing Address - Country:US
Mailing Address - Phone:405-216-5444
Mailing Address - Fax:405-216-5445
Practice Address - Street 1:3863 S. BOULEVARD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034
Practice Address - Country:US
Practice Address - Phone:405-216-5444
Practice Address - Fax:405-216-5445
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18783207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100152170BMedicaid
OKF75603Medicare UPIN
OK241413204Medicare ID - Type UnspecifiedINDIVIDUAL