Provider Demographics
NPI:1205122967
Name:KOO, SELENE CLARISSA (MD, PHD)
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:CLARISSA
Last Name:KOO
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 DANNY THOMAS PL # MS 515
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:888-226-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125059369207ZP0102X
OH35.132164207ZP0102X
TN62776207ZP0213X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology