Provider Demographics
NPI:1104824044
Name:KOCH, JOHN KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEVIN
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:800 GRAND CENTRAL MALL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4100
Mailing Address - Country:US
Mailing Address - Phone:304-865-4350
Mailing Address - Fax:304-865-4348
Practice Address - Street 1:800 GRAND CENTRAL MALL
Practice Address - Street 2:SUITE 2
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4100
Practice Address - Country:US
Practice Address - Phone:304-865-4350
Practice Address - Fax:304-865-4348
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2011-08-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV19553208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011154000Medicaid
OH2197448Medicaid
OH311599387-00OtherWORKERS COMP
201655OtherFEDERAL BLACK LUNG
WV311599387003OtherMOUTAIN STATE BCBS
WV9298571OtherMEDICARE PTAN
G85618Medicare UPIN