Provider Demographics
NPI:1699777268
Name:KOONTZ, WILLIAM L (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:KOONTZ
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 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-899-6755
Mailing Address - Fax:502-899-6753
Practice Address - Street 1:4121 DUTCHMANS LN
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4707
Practice Address - Country:US
Practice Address - Phone:502-899-6755
Practice Address - Fax:502-899-6753
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22633207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64226335Medicaid
KYK024790OtherMEDICARE- WOMEN'S SPECIALISTS
0386209Medicare ID - Type Unspecified
0386109Medicare ID - Type Unspecified
KY64226335Medicaid
KYK024790OtherMEDICARE- WOMEN'S SPECIALISTS