Provider Demographics
NPI:1275826307
Name:JOHN J KOO MD INC
Entity Type:Organization
Organization Name:JOHN J KOO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-352-1981
Mailing Address - Street 1:PO BOX 25490
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-0490
Mailing Address - Country:US
Mailing Address - Phone:808-536-0300
Mailing Address - Fax:808-536-0320
Practice Address - Street 1:640 ULUKAHIKI ST
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4454
Practice Address - Country:US
Practice Address - Phone:808-263-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-14092207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI591041Medicaid