Basic Information
| Provider Information | |||||||||
| NPI: | 1508876871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOELLIKER | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 LIGHTHOUSE LN | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028062829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012452389 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2014 WASHINGTON ST | ||||||||
| Address2: | PATHOLOGY DEPARTMENT, NEWTON-WELLESLEY HOSPITAL | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024621607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172436140 | ||||||||
| FaxNumber: | 6172435809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207ZC0500X | 79822 | MA | X | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 79822 | MA | X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000021384 | 01 | BOSTON CITY HEALTH NET | OTHER | 3126374 | 05 | MA | MEDICAID | 34725 | 01 | HARVARD-PILGRIM HEALTH | OTHER | 34802 | 01 | HARVARD PILGRIM HEALTH | OTHER | 34802 | 01 | HPHCFIRST SENIORITY | OTHER | 803550 | 01 | SECURE HORIZONS | OTHER | 737777 | 01 | TUFTS HEALTH PLAN POS | OTHER | KOJ30752 | 01 | BC/BS MASS | OTHER |