Provider Demographics
NPI:1457345894
Name:KOO, CHOON WON (MD)
Entity type:Individual
Prefix:
First Name:CHOON
Middle Name:WON
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 1:760 S WASHBURN AVE
Mailing Address - Street 2:STE 3A
Mailing Address - City:CORENA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3303
Mailing Address - Country:US
Mailing Address - Phone:951-734-7200
Mailing Address - Fax:951-734-5057
Practice Address - Street 1:760 S WASHBURN AVE
Practice Address - Street 2:STE 3A
Practice Address - City:CORENA
Practice Address - State:CA
Practice Address - Zip Code:92882-3303
Practice Address - Country:US
Practice Address - Phone:951-734-7200
Practice Address - Fax:951-734-5057
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32373207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A323730Medicaid
A26734Medicare UPIN
CA00A323730Medicaid