Healthcare Provider Details

I. General information

NPI: 1740280916
Provider Name (Legal Business Name): JOHN P KOOTZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 DRESDEN AVE
GARDINER ME
04345-2615
US

IV. Provider business mailing address

152 DRESDEN AVE
GARDINER ME
04345-2615
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-6608
  • Fax: 207-582-2258
Mailing address:
  • Phone: 207-582-6608
  • Fax: 207-582-2258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number012564
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: