Provider Demographics
NPI:1972604197
Name:KOOI, PANG LAY (MD)
Entity Type:Individual
Prefix:DR
First Name:PANG
Middle Name:LAY
Last Name:KOOI
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 1:311 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2782
Mailing Address - Country:US
Mailing Address - Phone:207-323-7480
Mailing Address - Fax:888-864-4428
Practice Address - Street 1:195 GENESEE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3302
Practice Address - Country:US
Practice Address - Phone:315-252-8800
Practice Address - Fax:315-258-3938
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1254471302F00000X
NY125447208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00457043Medicaid
NYJ400002471Medicare PIN
NYB81629Medicare UPIN
NY00457043Medicaid