Provider Demographics
NPI:1720005317
Name:KOO, JASON T (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:T
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 1:13249 CASCADE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7146
Mailing Address - Country:US
Mailing Address - Phone:801-572-5226
Mailing Address - Fax:
Practice Address - Street 1:13249 CASCADE GLEN DR
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7146
Practice Address - Country:US
Practice Address - Phone:801-572-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM11882086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173049102Medicaid
TX8D9918Medicare ID - Type Unspecified
H87884Medicare UPIN