Provider Demographics
NPI:1316960933
Name:KOONTZ, FREDERICK ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:ALAN
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:145 KIMEL PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6984
Mailing Address - Country:US
Mailing Address - Phone:336-768-3212
Mailing Address - Fax:336-768-9019
Practice Address - Street 1:145 KIMEL PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6984
Practice Address - Country:US
Practice Address - Phone:336-768-3212
Practice Address - Fax:336-768-9019
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC20926207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8950054Medicaid
P00185775OtherRR MEDICARE
NC1374COtherBCBS
P00185775OtherRR MEDICARE
E16419Medicare UPIN