Provider Demographics
NPI:1134174949
Name:KOOIKER, KEVIN PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PAUL
Last Name:KOOIKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 LYNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4362
Mailing Address - Country:US
Mailing Address - Phone:612-978-1086
Mailing Address - Fax:
Practice Address - Street 1:1515 LYNDALE AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4362
Practice Address - Country:US
Practice Address - Phone:612-978-1086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30773207P00000X
WI61479207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN588085800Medicaid
MNB36692Medicare UPIN