Provider Demographics
NPI:1073775532
Name:KOOLA, JEJO D (MD)
Entity Type:Individual
Prefix:
First Name:JEJO
Middle Name:D
Last Name:KOOLA
Suffix:
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:619-471-9186
Practice Address - Fax:619-543-8255
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5199207R00000X
TN50317207R00000X
SCTL34447207R00000X
CAA122014207R00000X, 208M00000X
NMMD2011-0624207R00000X
VA0101250440207R00000X
WA60264643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine