Provider Demographics
NPI:1881784775
Name:KOERITZ, KENNETH WALTER JR (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WALTER
Last Name:KOERITZ
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 AMBASSADOR DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8944
Mailing Address - Country:US
Mailing Address - Phone:254-752-4395
Mailing Address - Fax:254-752-7343
Practice Address - Street 1:2501 AMBASSADOR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8944
Practice Address - Country:US
Practice Address - Phone:254-752-4395
Practice Address - Fax:254-752-7343
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0530207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097556702Medicaid
D95811Medicare UPIN
TX097556702Medicaid