Provider Demographics
NPI:1114036829
Name:KOCH, DONALD F (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:F
Last Name:KOCH
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 1:176 SPRING LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-4678
Mailing Address - Country:US
Mailing Address - Phone:708-638-1229
Mailing Address - Fax:239-304-3681
Practice Address - Street 1:33 W DELAWARE PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-8115
Practice Address - Country:US
Practice Address - Phone:708-386-6565
Practice Address - Fax:708-386-6589
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360401592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036040159Medicaid
ILC38801Medicare UPIN