MEDICARE: DIANA E KOELLIKER 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	207P00000X	Emergency Medicine Physician	DR.0042229	CO

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	:	1871567883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA E KOELLIKER M.D.

Provider Business Mailing Address
First Line	:	500 W PACIFIC AVE
Second Line	:	PO BOX 1229
City	:	TELLURIDE
State	:	CO
Zip	:	81435-1229
Country	:	US
Telephone Number	:	970-728-3848
Fax Number	:	970-728-3404

Provider Business Practice Location Address
First Line	:	500 W PACIFIC AVE
Second Line	:
City	:	TELLURIDE
State	:	CO
Zip	:	81435-1229
Country	:	US
Telephone Number	:	970-728-3848
Fax Number	:	970-728-3404

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

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	09/02/2015

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