Healthcare Provider Details

I. General information

NPI: 1417921453
Provider Name (Legal Business Name): PAUL D KOELLIKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12033 AGENCY RD
PARKER AZ
85344-7718
US

IV. Provider business mailing address

12033 AGENCY RD
PARKER AZ
85344-7718
US

V. Phone/Fax

Practice location:
  • Phone: 928-669-3353
  • Fax: 928-669-3131
Mailing address:
  • Phone: 928-669-3353
  • Fax: 928-669-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2001-235
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: