Provider Demographics
NPI:1326028507
Name:KOO, EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
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 1:934 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2172
Mailing Address - Country:US
Mailing Address - Phone:847-942-6120
Mailing Address - Fax:
Practice Address - Street 1:934 WESLEY DR
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2172
Practice Address - Country:US
Practice Address - Phone:847-942-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-22
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI30414Medicare UPIN