Healthcare Provider Details

I. General information

NPI: 1093943821
Provider Name (Legal Business Name): JASON WYETH KOOB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 NORRIS CANYON RD
SAN RAMON CA
94583-5400
US

IV. Provider business mailing address

3494 CAMINO TASSAJARA # 1010
DANVILLE CA
94506-4680
US

V. Phone/Fax

Practice location:
  • Phone: 925-275-9200
  • Fax: 925-308-8944
Mailing address:
  • Phone: 925-275-9200
  • Fax: 925-308-8944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA128794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: