MEDICARE: JOHN P KOOTZ M.D

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	207Q00000X	Family Medicine Physician	012564	ME

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

General Provider Information

NPI Number	:	1740280916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN P KOOTZ M.D

Provider Business Mailing Address
First Line	:	152 DRESDEN AVE
Second Line	:
City	:	GARDINER
State	:	ME
Zip	:	04345-2615
Country	:	US
Telephone Number	:	207-582-6608
Fax Number	:	207-582-2258

Provider Business Practice Location Address
First Line	:	152 DRESDEN AVE
Second Line	:
City	:	GARDINER
State	:	ME
Zip	:	04345-2615
Country	:	US
Telephone Number	:	207-582-6608
Fax Number	:	207-582-2258

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	10/16/2012

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Directions to “ JOHN P KOOTZ M.D” Practice Location

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