Healthcare Provider Details

I. General information

NPI: 1487645370
Provider Name (Legal Business Name): MICHAEL KOOYMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2649 W HORIZON RIDGE PKWY 100
HENDERSON NV
89052-4801
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-565-6641
  • Fax: 702-565-9249
Mailing address:
  • Phone: 702-565-6641
  • Fax: 702-565-9249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0503
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: