Healthcare Provider Details

I. General information

NPI: 1730281668
Provider Name (Legal Business Name): ANDREW LEE-WAH KOO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

IV. Provider business mailing address

215 N MAIN ST
WHITE RIVER JUNCTION VT
05009-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number14590
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042-0011961
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number042-0011961
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: