Healthcare Provider Details

I. General information

NPI: 1902930209
Provider Name (Legal Business Name): GLENN KOESTER, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3863 S BOULEVARD ST STE 200
EDMOND OK
73013-5540
US

IV. Provider business mailing address

3863 S BOULEVARD ST STE 200
EDMOND OK
73013-5540
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-5444
  • Fax:
Mailing address:
  • Phone: 405-216-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number18783
License Number StateOK

VIII. Authorized Official

Name: GLENN KOESTER
Title or Position: M.D.
Credential: M.D.
Phone: 405-216-5444