Provider Demographics
NPI:1134198120
Name:KOESTERS, IRENE (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KOESTERS
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 1:4775 KNIGHTSBRIDGE BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4313
Mailing Address - Country:US
Mailing Address - Phone:614-442-5557
Mailing Address - Fax:614-442-1070
Practice Address - Street 1:4775 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4313
Practice Address - Country:US
Practice Address - Phone:614-442-5557
Practice Address - Fax:614-442-1070
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082264208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000356506OtherANTHEM
OH7634634OtherAETNA HMO
OH2545946OtherBCMH
311268558032OtherCARESOURCE
OH2545946Medicaid
OH7634634OtherAETNA
OH7634634OtherAETNA