Provider Demographics
NPI:1023088960
Name:KOEZE, URSULA GAILLIOT (MD)
Entity type:Individual
Prefix:DR
First Name:URSULA
Middle Name:GAILLIOT
Last Name:KOEZE
Suffix:
Gender:F
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:PO BOX 11647
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-1647
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:459 LOCUST AVE
Practice Address - Street 2:MB 26
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-4808
Practice Address - Country:US
Practice Address - Phone:434-982-7150
Practice Address - Fax:434-982-7147
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057124207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA29797Medicaid
VA166192OtherANTHEM SVC/HEALTHKEEPERS
VA29797OtherCOMMUNITY HEALTH
VA010142890Medicaid
VA224992OtherSOUTHERN HEALTH
VA930113085OtherMEDICARE PIN
VAP00206926OtherMEDICARE PIN
G67412Medicare UPIN
VA29797OtherCOMMUNITY HEALTH
VA930113085OtherMEDICARE PIN