Provider Demographics
NPI:1992746580
Name:KOONSMAN, MARTIN LEROY JR (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LEROY
Last Name:KOONSMAN
Suffix:JR
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:PAV II, SUITE 532
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208
Practice Address - Country:US
Practice Address - Phone:214-943-8605
Practice Address - Fax:214-946-8339
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6352208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01100125OtherRAILROAD MEDICARE
TX097588001Medicaid
TX020027451OtherRR-MEDICARE
TX097588003Medicaid
TX88T751Medicare ID - Type Unspecified
TX097588003Medicaid
TX020027451OtherRR-MEDICARE