Provider Demographics
NPI:1437709383
Name:KOO, GINA JUNG EUN (OD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:JUNG EUN
Last Name:KOO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JUNG EUN
Other - Middle Name:
Other - Last Name:KOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6727 SYLMAR AVE APT 209
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4703
Mailing Address - Country:US
Mailing Address - Phone:818-405-6404
Mailing Address - Fax:
Practice Address - Street 1:6727 SYLMAR AVE APT 209
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4703
Practice Address - Country:US
Practice Address - Phone:818-405-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002819152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist