Provider Demographics
NPI:1306841044
Name:KOO, DAVID G (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:G
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 1:1737 DAVID WALKER DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5745
Mailing Address - Country:US
Mailing Address - Phone:352-742-8836
Mailing Address - Fax:352-742-8829
Practice Address - Street 1:1000 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-742-8836
Practice Address - Fax:352-742-8829
Is Sole Proprietor?:No
Enumeration Date:2005-06-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108164207Q00000X, 208M00000X
OH35075829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2161128Medicaid
OHKO2020051Medicare ID - Type Unspecified
OHG93820Medicare UPIN