Provider Demographics
NPI:1205801628
Name:KOEWLER, THOMAS JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:KOEWLER
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14214 BALLANTYNE LAKE RD
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3372
Practice Address - Country:US
Practice Address - Phone:704-667-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01821208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910820Medicaid
NC1205801628Medicaid
SC318098Medicaid
SCAA44527772Medicare PIN
SC318098Medicaid
NC2022967GMedicare PIN
NC2022967Medicare PIN
WAG71758Medicare UPIN
NCNC4230CMedicare UPIN
NCNC4230BMedicare UPIN
NC2022967DMedicare PIN
NC2022967CMedicare PIN
NC2022967NMedicare PIN
NC2022967BMedicare PIN
NCNC4230DMedicare PIN
NC2022967PMedicare PIN
NCNC4230EMedicare PIN
NCNC4230FMedicare PIN
NC2022967AMedicare PIN
NC1205801628Medicaid
NC2022967HMedicare PIN
NC2022967JMedicare PIN
NC2022967MMedicare PIN
NC2022967FMedicare PIN
NC2022967EMedicare PIN