Provider Demographics
NPI:1932250834
Name:KOOP, TIMOTHY GERRIT (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GERRIT
Last Name:KOOP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 LEES CHAPEL RD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2599
Mailing Address - Country:US
Mailing Address - Phone:336-271-2020
Mailing Address - Fax:336-275-8200
Practice Address - Street 1:1305 LEES CHAPEL RD.
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2599
Practice Address - Country:US
Practice Address - Phone:336-271-2020
Practice Address - Fax:336-275-8200
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1666152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890927MMedicaid
NC2470683EMedicare ID - Type Unspecified
NC890927MMedicaid