Provider Demographics
NPI:1528068228
Name:KOONS, DEXTER D (MD)
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:D
Last Name:KOONS
Suffix:
Gender:M
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:PO BOX 8561
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-8516
Mailing Address - Country:US
Mailing Address - Phone:719-320-3515
Mailing Address - Fax:719-543-1309
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-320-3515
Practice Address - Fax:719-543-1309
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28413207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01284132Medicaid
COC419318Medicare PIN