Provider Demographics
NPI:1205895943
Name:KOO, GREGORY THOMAS (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
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 1:496 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1827
Mailing Address - Country:US
Mailing Address - Phone:859-288-2425
Mailing Address - Fax:859-288-7510
Practice Address - Street 1:576 E THIRD ST STE 170
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-2251
Practice Address - Country:US
Practice Address - Phone:859-288-2425
Practice Address - Fax:859-288-7510
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33614174400000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64363146Medicaid
OH2388170Medicaid
OH2388170Medicaid
KY080152814Medicare PIN
P00844265Medicare PIN
KY00954028Medicare PIN
KY0364937Medicare PIN