Provider Demographics
NPI:1497899728
Name:KOO, MARTHA BREWER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:BREWER
Last Name:KOO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:310-318-5566
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:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78080101YM0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG78080Medicare ID - Type Unspecified