Provider Demographics
NPI:1619954377
Name:KOON, DAVID T JR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:KOON
Suffix:JR
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 10
Mailing Address - Street 2:123 MAIN ST
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-0010
Mailing Address - Country:US
Mailing Address - Phone:803-485-2240
Mailing Address - Fax:803-485-2219
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148
Practice Address - Country:US
Practice Address - Phone:803-485-2240
Practice Address - Fax:803-485-2219
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7161OtherMEDICARE
SC7382016OtherAETNA
SCA7980OtherMEDCOST
SC0141069OtherCAROLINA CARE
SC196512Medicaid
SC5161OtherCOMPANION
F89192Medicare UPIN