Provider Demographics
NPI:1437290590
Name:KOON, CHARLES STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:STEPHEN
Last Name:KOON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-2015
Mailing Address - Country:US
Mailing Address - Phone:937-773-8905
Mailing Address - Fax:937-778-8465
Practice Address - Street 1:615 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-2015
Practice Address - Country:US
Practice Address - Phone:937-773-8905
Practice Address - Fax:937-778-8465
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2849 T523152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0458550001Medicare NSC
OHT46130Medicare UPIN