Provider Demographics
NPI:1245289594
Name:KOO, JOHN YM (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:YM
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 1:1635 DIVISADERO STREET, SUITE 625, BOX 1821
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:415-476-4029
Mailing Address - Fax:415-476-4150
Practice Address - Street 1:515 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-2616
Practice Address - Country:US
Practice Address - Phone:415-476-4701
Practice Address - Fax:415-502-4126
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48584207N00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0G4858400Medicaid
CAE35886Medicare UPIN
CA0G4858400Medicaid