Provider Demographics
NPI:1801851316
Name:KOERBER, MITCHELL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:LEE
Last Name:KOERBER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26187-1299
Mailing Address - Country:US
Mailing Address - Phone:304-375-6468
Mailing Address - Fax:304-375-6468
Practice Address - Street 1:442 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:WV
Practice Address - Zip Code:26187-1249
Practice Address - Country:US
Practice Address - Phone:304-375-6468
Practice Address - Fax:304-375-6468
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV937OD152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149872000Medicaid
WV0149872000Medicaid
WV4036041Medicare PIN