Provider Demographics
NPI:1467626184
Name:KOO, NATHANIEL
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:KOO
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 1:1012 N WOOD ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3261
Mailing Address - Country:US
Mailing Address - Phone:847-903-7507
Mailing Address - Fax:
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:SUITE 518-E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-6765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361337742086S0120X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery