Provider Demographics
NPI:1023068384
Name:KOOP, DARRYL GLEN (MD)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:GLEN
Last Name:KOOP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:600 N PICKAWAY ST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-2409
Practice Address - Country:US
Practice Address - Phone:740-474-2126
Practice Address - Fax:740-477-1022
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070336K207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00120093OtherRR CIRCLEVILLE
OH000000316757OtherBCBS
OH2055289Medicaid
G67270Medicare UPIN
OH000000316757OtherBCBS