Healthcare Provider Details

I. General information

NPI: 1487848404
Provider Name (Legal Business Name): MARTHA B. KOO, M.D., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2007
Last Update Date: 09/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 PACIFIC COAST HWY 215
HERMOSA BEACH CA
90254-2225
US

IV. Provider business mailing address

515 LARSSON ST
MANHATTAN BEACH CA
90266-6734
US

V. Phone/Fax

Practice location:
  • Phone: 310-318-2566
  • Fax:
Mailing address:
  • Phone: 310-318-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberG78080
License Number StateCA

VIII. Authorized Official

Name: DR. MARTHA KOO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-318-2566