Healthcare Provider Details

I. General information

NPI: 1609010156
Provider Name (Legal Business Name): THADEUS B KOONTZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2034 DE LA VINA ST
SANTA BARBARA CA
93105-3814
US

IV. Provider business mailing address

3340 E GOLDSTONE DR
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 805-681-5450
  • Fax: 805-884-6888
Mailing address:
  • Phone: 208-367-2175
  • Fax: 208-376-0285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM-11984
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM11984
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-11984
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: