Provider Demographics
NPI:1508854605
Name:VAN KOOY, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:VAN KOOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 AUTUMN DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLINVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08322-2423
Mailing Address - Country:US
Mailing Address - Phone:856-562-8678
Mailing Address - Fax:
Practice Address - Street 1:1751 AUTUMN DR
Practice Address - Street 2:
Practice Address - City:FRANKLINVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08322-2423
Practice Address - Country:US
Practice Address - Phone:856-562-8678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03950700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1179504Medicaid
NJ007600R63Medicare ID - Type Unspecified
NJ1179504Medicaid