Provider Demographics
NPI:1821609678
Name:KOONTZ, MATTHEW GLEN (RD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:GLEN
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16550 NE 79TH ST APT 121
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-2474
Mailing Address - Country:US
Mailing Address - Phone:425-633-2022
Mailing Address - Fax:
Practice Address - Street 1:10900 NE 4TH ST STE 2300
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5882
Practice Address - Country:US
Practice Address - Phone:425-633-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered