Provider Demographics
NPI:1730193137
Name:KOONTZ, DAVID W (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MESSIMER DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1525
Mailing Address - Country:US
Mailing Address - Phone:740-788-9633
Mailing Address - Fax:740-788-9649
Practice Address - Street 1:30 MESSIMER DRIVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1525
Practice Address - Country:US
Practice Address - Phone:740-788-9633
Practice Address - Fax:740-788-9649
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004321207R00000X
OHK34004321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0747204Medicaid
E58890Medicare UPIN
OH0747204Medicaid