Healthcare Provider Details

I. General information

NPI: 1619954377
Provider Name (Legal Business Name): DAVID T KOON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MAIN ST
SUMMERTON SC
29148
US

IV. Provider business mailing address

PO BOX 10 123 MAIN ST
SUMMERTON SC
29148-0010
US

V. Phone/Fax

Practice location:
  • Phone: 803-485-2240
  • Fax: 803-485-2219
Mailing address:
  • Phone: 803-485-2240
  • Fax: 803-485-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19651
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: