MEDICARE: MICHAEL KOOYMAN DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	0503	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487645370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL KOOYMAN DPM

Provider Business Mailing Address
First Line	:	PO BOX 15645
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89114-5645
Country	:	US
Telephone Number	:	702-565-6641
Fax Number	:	702-565-9249

Provider Business Practice Location Address
First Line	:	2649 W HORIZON RIDGE PKWY
Second Line	:	100
City	:	HENDERSON
State	:	NV
Zip	:	89052-4801
Country	:	US
Telephone Number	:	702-565-6641
Fax Number	:	702-565-9249

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	02/14/2014

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