Provider Demographics
NPI:1073577037
Name:KOON, DAVID EDWIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDWIN
Last Name:KOON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22265
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4473
Mailing Address - Country:US
Mailing Address - Phone:803-296-7846
Mailing Address - Fax:803-296-9699
Practice Address - Street 1:300 PALMETTO HEALTH PKWY STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1762
Practice Address - Country:US
Practice Address - Phone:803-434-6812
Practice Address - Fax:803-434-7306
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC16729207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC167296Medicaid
SC0534520001OtherMEDICARE DME
SC167296Medicaid
SC0534520001OtherMEDICARE DME
SC0534520001Medicare NSC
SCH570062488Medicare PIN
H57006Medicare UPIN