Healthcare Provider Details

I. General information

NPI: 1083802128
Provider Name (Legal Business Name): SANG-WAHN KOO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 15245 BOX BRIAN
APO AP
96271-5245
US

IV. Provider business mailing address

UNIT 15281 BOX USAMEDDA
APO AP
96271-5281
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-5817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME133410
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME133410
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number31708
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: