Provider Demographics
NPI:1053754622
Name:KOOISTRA, HESSEL III (MD)
Entity type:Individual
Prefix:DR
First Name:HESSEL
Middle Name:
Last Name:KOOISTRA
Suffix:III
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 1:10975 ROCKY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-0614
Mailing Address - Country:US
Mailing Address - Phone:479-841-2736
Mailing Address - Fax:
Practice Address - Street 1:10971 ROCKY CREEK RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-0614
Practice Address - Country:US
Practice Address - Phone:479-841-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2570208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000516J3Medicaid
TXP000516J3Medicaid
G98249Medicare UPIN