Healthcare Provider Details

I. General information

NPI: 1063456218
Provider Name (Legal Business Name): KURT WILLIAM KOOYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 UNIVERSITY DR S
FARGO ND
58103-6050
US

IV. Provider business mailing address

641 COTTONWOOD CT
WEST FARGO ND
58078-3144
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-9000
  • Fax: 701-893-9057
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9202
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9202
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier12025
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: