Basic Information
| Provider Information | |||||||||
| NPI: | 1942237714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOONS | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | CLYDE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4645 NW 8TH AVE | ||||||||
| Address2: | INTERVENTIONAL CARDIOLOGISTS OF GAINESVILLE | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523318570 | ||||||||
| FaxNumber: | 3523319095 | ||||||||
| Practice Location | |||||||||
| Address1: | 4645 NW 8TH AVE | ||||||||
| Address2: | INTERVENTIONAL CARDIOLOGISTS OF GAINESVILLE | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523318570 | ||||||||
| FaxNumber: | 3523319095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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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 | 207RC0000X | ME55736 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | ME55736 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | CM8550 | 01 | FL | MEDICARE RR | OTHER | 377799500 | 05 | FL | MEDICAID | 26952 | 01 | FL | BLUECROSS FL | OTHER |