Provider Demographics
NPI:1013967140
Name:KOEHLER, KATHLEEN E (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:EAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:364 STATE RD
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-5624
Mailing Address - Country:US
Mailing Address - Phone:508-693-4400
Mailing Address - Fax:086-932-0985
Practice Address - Street 1:364 STATE RD
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-5624
Practice Address - Country:US
Practice Address - Phone:508-693-4400
Practice Address - Fax:508-693-2098
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49598207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2029341Medicaid
MAJ04688OtherBCBS
MAAA6332OtherHPHC
MAJ04688OtherBCBS
MA2029341Medicaid