Basic Information
| Provider Information | |||||||||
| NPI: | 1104400373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOO | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | HYUNMO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5133 MARATHON PKWY | ||||||||
| Address2: | |||||||||
| City: | LITTLE NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113621716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3478841949 | ||||||||
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| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014448809 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2021 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NY | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.