Provider Demographics
NPI:1992789689
Name:KOSTER, DANIEL G (MD SC)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:G
Last Name:KOSTER
Suffix:
Gender:M
Credentials:MD SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 S WEBSTER AVE STE 1C
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3528
Mailing Address - Country:US
Mailing Address - Phone:920-433-3486
Mailing Address - Fax:920-433-7994
Practice Address - Street 1:704 S WEBSTER AVE STE 1C
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-3486
Practice Address - Fax:920-433-7994
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV29565OtherLICENSE
WI000107007Medicare Oscar/Certification
WI002150044Medicare Oscar/Certification
WIE80030Medicare UPIN