Healthcare Provider Details

I. General information

NPI: 1255782843
Provider Name (Legal Business Name): SETH TYLER KOEHLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2016
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 E MAIN ST
JACKSON MO
63755-2473
US

IV. Provider business mailing address

2600 E MAIN ST
JACKSON MO
63755-2473
US

V. Phone/Fax

Practice location:
  • Phone: 573-755-2310
  • Fax: 573-519-4675
Mailing address:
  • Phone: 573-755-2310
  • Fax: 573-519-4675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2018007982
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: