Provider Demographics
NPI:1689643389
Name:KOO, KYUNG W (MD)
Entity Type:Individual
Prefix:MR
First Name:KYUNG
Middle Name:W
Last Name:KOO
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 1:37W 638 YORK LANE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124
Mailing Address - Country:US
Mailing Address - Phone:847-608-7879
Mailing Address - Fax:
Practice Address - Street 1:745 FLETCHER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4747
Practice Address - Country:US
Practice Address - Phone:847-742-3525
Practice Address - Fax:847-742-3585
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048555207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3648555Medicaid
IL3648555Medicaid
ILK07750Medicare ID - Type Unspecified