Provider Demographics
NPI:1487848404
Name:MARTHA B. KOO, M.D., LTD.
Entity Type:Organization
Organization Name:MARTHA B. KOO, M.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-318-2566
Mailing Address - Street 1:515 LARSSON ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6734
Mailing Address - Country:US
Mailing Address - Phone:310-318-2566
Mailing Address - Fax:
Practice Address - Street 1:2615 PACIFIC COAST HWY
Practice Address - Street 2:215
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2225
Practice Address - Country:US
Practice Address - Phone:310-318-2566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-03
Last Update Date:2007-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78080261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19721Medicare PIN