Provider Demographics
NPI:1558364455
Name:KOOP, DOUGLAS P (DPT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
Last Name:KOOP
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4859 W SYLVANIA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3372
Mailing Address - Country:US
Mailing Address - Phone:419-471-0400
Mailing Address - Fax:419-471-0403
Practice Address - Street 1:4859 W SYLVANIA AVE STE A
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3372
Practice Address - Country:US
Practice Address - Phone:419-471-0400
Practice Address - Fax:419-471-0403
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-09627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2714192Medicaid
OHKO4196611Medicare PIN