Provider Demographics
NPI:1770531444
Name:KOESTER, THERESA R (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:R
Last Name:KOESTER
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 1:2900 CHANCELLOR DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5427
Mailing Address - Country:US
Mailing Address - Phone:859-363-2142
Mailing Address - Fax:859-363-2140
Practice Address - Street 1:2900 CHANCELLOR DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-5427
Practice Address - Country:US
Practice Address - Phone:859-363-2142
Practice Address - Fax:859-363-2140
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27960207R00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200944760Medicaid
000000479137OtherANTHEM
KY64279607Medicaid
310674100OtherFEDERAL BLACK LUNG
4296182OtherAETNA
50013712OtherPASSPORT
KY64279607Medicaid
KY00415005Medicare PIN
50013712OtherPASSPORT
E95884Medicare UPIN
KY0969427Medicare PIN
KYP00327533Medicare PIN
KY0399020Medicare PIN