Provider Demographics
NPI:1942275771
Name:KOELLA, JOHN ERIC (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ERIC
Last Name:KOELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:NORTHEASTERN VT REGIONAL HOSPITAL
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0905
Mailing Address - Country:US
Mailing Address - Phone:802-748-8141
Mailing Address - Fax:802-748-4098
Practice Address - Street 1:1315 HOSPITAL DR
Practice Address - Street 2:NORTHEASTERN VT REGIONAL HOSPITAL
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9210
Practice Address - Country:US
Practice Address - Phone:802-748-8141
Practice Address - Fax:802-748-4098
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY200876207Q00000X
VT042-0013372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10020809OtherCDPHP
NY000401661005OtherBLUE SHIELD
NY040426007236OtherFIDELIS
NY000000042317OtherGHI
NY9X3071OtherEMPIRE BLUE CROSS
NY958301OtherMVP
NY01592667Medicaid
NY43790OtherGHI HMO
NY5968600OtherAETNA
NY000000042317OtherGHI
NY9X3071OtherEMPIRE BLUE CROSS