Provider Demographics
NPI:1184917833
Name:KOOP, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:KOOP
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-428-5770
Mailing Address - Fax:859-428-5780
Practice Address - Street 1:7370 TURFWAY RD
Practice Address - Street 2:STE 390
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042
Practice Address - Country:US
Practice Address - Phone:859-212-5125
Practice Address - Fax:859-212-5099
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.015507207V00000X
KY45549207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070053Medicaid
KY7100206600Medicaid
KYP01103044OtherRR MEDICARE
IN201164500Medicaid
KY7100206600Medicaid