Provider Demographics
NPI:1609091081
Name:KOE, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:KOE
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:PO BOX 2250
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-2250
Mailing Address - Country:US
Mailing Address - Phone:904-269-9777
Mailing Address - Fax:904-264-9774
Practice Address - Street 1:1543 KINGSLEY AVENUE
Practice Address - Street 2:BUILDING #12
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-269-9777
Practice Address - Fax:904-264-9774
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0039855207R00000X
FLME0039855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066967900Medicaid
10970Medicare PIN
E81800Medicare UPIN