Provider Demographics
NPI:1265420509
Name:KOONTZ, DOUGLAS R (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 PEBBLE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-2910
Mailing Address - Country:US
Mailing Address - Phone:214-799-6795
Mailing Address - Fax:469-353-8390
Practice Address - Street 1:4230 PEBBLE CREEK CT
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-2910
Practice Address - Country:US
Practice Address - Phone:214-799-6795
Practice Address - Fax:469-353-8390
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13775207T00000X
NY268200207T00000X
VA0101257495207T00000X
SC37815207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100118150AMedicaid
C95123Medicare UPIN
OK900522063Medicare ID - Type Unspecified
OK100118150AMedicaid