Healthcare Provider Details

I. General information

NPI: 1205895943
Provider Name (Legal Business Name): GREGORY T KOO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HARRODSBURG RD STE B165
LEXINGTON KY
40504-1726
US

IV. Provider business mailing address

PO BOX 39597
BELFAST ME
04915-1249
US

V. Phone/Fax

Practice location:
  • Phone: 859-288-2425
  • Fax: 859-288-7510
Mailing address:
  • Phone: 859-288-2425
  • Fax: 859-288-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number33614
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33614
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number33614
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: