Healthcare Provider Details

I. General information

NPI: 1467546796
Provider Name (Legal Business Name): MARTIN A. KOYLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

4800 SAND POINT WAY NE DIVISION OF UROLOGY W7729
SEATTLE WA
98105-3901
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-6000
  • Fax:
Mailing address:
  • Phone: 206-987-5893
  • Fax: 206-987-3925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberMD00048989
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: