1255574711 NPI number — DR. PAUL E. KOCH, OPTOMETRIST, P.C

Table of content: (NPI 1255574711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255574711 NPI number — DR. PAUL E. KOCH, OPTOMETRIST, P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. PAUL E. KOCH, OPTOMETRIST, P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255574711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
476999 HIGHWAY 95
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONDERAY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83852-9738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-255-5513
Provider Business Mailing Address Fax Number:
208-255-5823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476999 HIGHWAY 95
Provider Second Line Business Practice Location Address:
C/O WALMART VISION CENTER
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-9738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-255-5513
Provider Business Practice Location Address Fax Number:
208-255-5823
Provider Enumeration Date:
04/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KOCH
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
ERWIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-290-2401

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  ODP1026 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806343800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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