Provider Demographics
NPI:1457071060
Name:STEPHANIE L KOONCE MD
Entity Type:Organization
Organization Name:STEPHANIE L KOONCE MD
Other - Org Name:ECOSSE PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LEIGHANN
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-719-0862
Mailing Address - Street 1:8401 MILE TREE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4320
Mailing Address - Country:US
Mailing Address - Phone:479-719-0862
Mailing Address - Fax:
Practice Address - Street 1:3301 S MARKET ST STE 205
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-7700
Practice Address - Country:US
Practice Address - Phone:479-276-6888
Practice Address - Fax:479-309-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227580001Medicaid
OK200783620AMedicaid