Healthcare Provider Details

I. General information

NPI: 1093792608
Provider Name (Legal Business Name): JAMES FLETCHER KOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S MATSON ST
KERSHAW SC
29067-1506
US

IV. Provider business mailing address

206 S MATSON ST
KERSHAW SC
29067-1506
US

V. Phone/Fax

Practice location:
  • Phone: 803-475-1156
  • Fax: 803-475-1128
Mailing address:
  • Phone: 803-475-1156
  • Fax: 803-475-1128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18339
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: