1235194143 NPI number — DR. THOMAS KIRBY KOITHAN DO

Table of content: DR. THOMAS KIRBY KOITHAN DO (NPI 1235194143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235194143 NPI number — DR. THOMAS KIRBY KOITHAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOITHAN
Provider First Name:
THOMAS
Provider Middle Name:
KIRBY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235194143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
495 S. 51ST ST.
Provider Second Line Business Mailing Address:
UNIT #40
Provider Business Mailing Address City Name:
WEST DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50265-6984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-457-8931
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 82 PL
Provider Second Line Business Practice Location Address:
WADLE AND ASSOCIATES PC
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50322-4329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-270-1344
Provider Business Practice Location Address Fax Number:
515-270-6515
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  IOWA2799 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0106294 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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