Provider Demographics
NPI:1083652853
Name:KOCH, DONNA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:MARIE
Last Name:KOCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 PASSAIC STREET
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026
Mailing Address - Country:US
Mailing Address - Phone:973-777-2293
Mailing Address - Fax:973-777-9117
Practice Address - Street 1:297 PASSAIC STREET
Practice Address - Street 2:
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026
Practice Address - Country:US
Practice Address - Phone:973-777-2293
Practice Address - Fax:973-777-9117
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB069001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9081101Medicaid
NJ9081101Medicaid
NJ051894Medicare PIN