Provider Demographics
NPI:1902804495
Name:COULTAS, DAVID D (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:D
Last Name:COULTAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:217-757-7491
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:1606 W LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3707
Practice Address - Country:US
Practice Address - Phone:217-245-1421
Practice Address - Fax:217-243-1699
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45785Medicare UPIN
ILL70709Medicare ID - Type Unspecified