MEDICARE: DONALD J KOETS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	497	SC

General Provider Information

NPI Number	:	1235307240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONALD J KOETS

Provider Business Mailing Address
First Line	:	206 E 2ND NORTH ST
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29483-6858
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 E 2ND NORTH ST
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29483-6858
Country	:	US
Telephone Number	:	843-851-1037
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DONALD KOETS
Credential	:	OD
Telephone Number	:	843-851-1037

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	12/12/2008

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