Provider Demographics
NPI:1417005190
Name:KOOB, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KOOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 WHITEHORSE MERCERVILLE RD
Mailing Address - Street 2:SUITE 422
Mailing Address - City:MERCERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3831
Mailing Address - Country:US
Mailing Address - Phone:609-581-4700
Mailing Address - Fax:609-581-1506
Practice Address - Street 1:1245 WHITEHORSE MERCERVILLE RD
Practice Address - Street 2:SUITE 422
Practice Address - City:MERCERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08619-3831
Practice Address - Country:US
Practice Address - Phone:609-581-4700
Practice Address - Fax:609-581-1506
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00310500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist