MEDICARE: PIETER G KOOLEN MD, PHD

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	208200000X	Plastic Surgery Physician	BP10076785	TX

General Provider Information

NPI Number	:	1245800028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PIETER G KOOLEN MD, PHD

Provider Business Mailing Address
First Line	:	5253 FANNIN ST APT 2606
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-5875
Country	:	US
Telephone Number	:	--
Fax Number	:

Provider Business Practice Location Address
First Line	:	5253 FANNIN ST APT 2606
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-5875
Country	:	US
Telephone Number	:	--
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2021
Last Update Date	:	06/25/2021

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