Provider Demographics
NPI:1902930209
Name:GLENN KOESTER, M.D., P.C.
Entity Type:Organization
Organization Name:GLENN KOESTER, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-216-5444
Mailing Address - Street 1:3863 S BOULEVARD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5540
Mailing Address - Country:US
Mailing Address - Phone:405-216-5444
Mailing Address - Fax:
Practice Address - Street 1:3863 S BOULEVARD ST STE 200
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5540
Practice Address - Country:US
Practice Address - Phone:405-216-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18783207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK456922202001OtherBCBS IND
OKF75603Medicare UPIN