Provider Demographics
NPI:1912629387
Name:KOO, VICTOR S (DPT)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:S
Last Name:KOO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 E 17TH ST STE 650
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-4706
Mailing Address - Country:US
Mailing Address - Phone:949-722-7374
Mailing Address - Fax:
Practice Address - Street 1:6865 ALTON PKWY STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3740
Practice Address - Country:US
Practice Address - Phone:949-679-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT302741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist