Provider Demographics
NPI:1114280419
Name:KOO, JOHAN (DO)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:
Last Name:KOO
Suffix:
Gender:M
Credentials:DO
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8440
Practice Address - Street 1:108 PROMINENCE CT STE 200
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6340
Practice Address - Country:US
Practice Address - Phone:706-216-3238
Practice Address - Fax:706-216-5285
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA077166207Q00000X
GA77166207Q00000X
TN2708208M00000X
VA0102203635208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I087218Medicare PIN
VAVVH763BMedicare PIN