Healthcare Provider Details

I. General information

NPI: 1528043205
Provider Name (Legal Business Name): DAVID C KOON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 NW 22ND AVE SUITE 320
PORTLAND OR
97210-3057
US

IV. Provider business mailing address

1040 NW 22ND AVE SUITE 320
PORTLAND OR
97210-3057
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-6294
  • Fax: 503-413-7780
Mailing address:
  • Phone: 503-413-6294
  • Fax: 503-413-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD23367
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: