Provider Demographics
NPI:1093792608
Name:KOON, JAMES FLETCHER (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:FLETCHER
Last Name:KOON
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 1:206 S MATSON ST
Mailing Address - Street 2:
Mailing Address - City:KERSHAW
Mailing Address - State:SC
Mailing Address - Zip Code:29067-1506
Mailing Address - Country:US
Mailing Address - Phone:803-475-1156
Mailing Address - Fax:803-475-1128
Practice Address - Street 1:206 S MATSON ST
Practice Address - Street 2:
Practice Address - City:KERSHAW
Practice Address - State:SC
Practice Address - Zip Code:29067-1506
Practice Address - Country:US
Practice Address - Phone:803-475-1156
Practice Address - Fax:803-475-1128
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080179118OtherRETIRED RR MEDICARE
SC000000229650OtherUNISON
SC5532095OtherAETNA
SC8874326OtherPPNI
SCT24079Medicaid
SC01153584OtherAMERIGROUP
SC20071782OtherSELECT HEALTH
SC21149333031OtherBEECHSTREET
SCA8973OtherMEDCOST
SC3091345OtherCIGNA
SC0141069OtherCAROLINA CARE
SCA8973OtherMEDCOST
SCT24079Medicaid
SCG209688862Medicare PIN
SC8862Medicare PIN