Provider Demographics
NPI:1184747271
Name:KOONTZ, THOMAS (DC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:DC
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 381408
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1408
Mailing Address - Country:US
Mailing Address - Phone:901-362-2800
Mailing Address - Fax:901-624-9782
Practice Address - Street 1:1996 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3949
Practice Address - Country:US
Practice Address - Phone:901-362-2800
Practice Address - Fax:901-624-9782
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001115111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3084009OtherBLUECROSS BLUESHIELD
TN3679986Medicare ID - Type Unspecified