MEDICARE: KENNETH WALTER KOERITZ JR. MD

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	207V00000X	Obstetrics & Gynecology Physician	H0530	TX

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	:	1881784775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WALTER KOERITZ JR. MD

Provider Business Mailing Address
First Line	:	2501 AMBASSADOR DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-8944
Country	:	US
Telephone Number	:	254-752-4395
Fax Number	:	254-752-7343

Provider Business Practice Location Address
First Line	:	2501 AMBASSADOR DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-8944
Country	:	US
Telephone Number	:	254-752-4395
Fax Number	:	254-752-7343

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	02/16/2010

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