Basic Information
| Provider Information | |||||||||
| NPI: | 1396714218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOUKOL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7198666568 | ||||||||
| FaxNumber: | 7195382999 | ||||||||
| Practice Location | |||||||||
| Address1: | 2405 RESEARCH PARKWAY | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195221134 | ||||||||
| FaxNumber: | 7195987229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | DR.0024495 | CO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01244953 | 05 | CO | MEDICAID |