Provider Demographics
NPI:1679797088
Name:KOO, KERN SCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:KERN
Middle Name:SCOTT
Last Name:KOO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51-33 MARATHON PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362
Mailing Address - Country:US
Mailing Address - Phone:718-357-3458
Mailing Address - Fax:718-357-3483
Practice Address - Street 1:51-33 MARATHON PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362
Practice Address - Country:US
Practice Address - Phone:718-357-3458
Practice Address - Fax:718-357-3483
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H44807Medicare UPIN