Provider Demographics
NPI:1528220878
Name:KOO, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
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 1:7101 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3701
Mailing Address - Country:US
Mailing Address - Phone:561-515-1500
Mailing Address - Fax:
Practice Address - Street 1:7101 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3701
Practice Address - Country:US
Practice Address - Phone:561-515-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP01375207R00000X
MDD74079207W00000X
VT042.0012697207W00000X
FLME120645207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD055262300Medicaid
VT055262300Medicaid
VT241350YYUMedicare PIN