Provider Demographics
NPI:1144245606
Name:KOO, EDWARD H (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:H
Last Name:KOO
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 1:9500 GILMAN DR
Mailing Address - Street 2:MAIL CODE 0691
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-5004
Mailing Address - Country:US
Mailing Address - Phone:858-822-1024
Mailing Address - Fax:858-822-1021
Practice Address - Street 1:9500 GILMAN DR
Practice Address - Street 2:MAIL CODE 0691
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-5004
Practice Address - Country:US
Practice Address - Phone:858-822-1024
Practice Address - Fax:858-822-1021
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47266207ZN0500X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G472660Medicaid
CAWG47266AMedicare ID - Type Unspecified
CA00G472660Medicaid