Individual
DR. MICHAEL KOOISTRA JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1306 E 7TH ST STE A, AUBURN, IN 46706-2537
(260) 925-1255
(260) 925-1256
Mailing address
11109 PARKVIEW PLAZA DR # 117, FORT WAYNE, IN 46845-1701
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01045333A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01045333A
—
IN
05
—
200115800
—
IN
Enumeration date
07/14/2005
Last updated
01/02/2024
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