Provider Demographics
NPI:1750455150
Name:KOEHLER, DANITA NEVITT (MD)
Entity type:Individual
Prefix:DR
First Name:DANITA
Middle Name:NEVITT
Last Name:KOEHLER
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:HC 62 BOX 5217
Mailing Address - Street 2:
Mailing Address - City:DELTA JUNCTION
Mailing Address - State:AK
Mailing Address - Zip Code:99737-9601
Mailing Address - Country:US
Mailing Address - Phone:907-323-3034
Mailing Address - Fax:
Practice Address - Street 1:1060 GAFFNEY RD
Practice Address - Street 2:
Practice Address - City:FT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5001
Practice Address - Country:US
Practice Address - Phone:907-361-5345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3184207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK11272Medicaid
AK11272Medicaid