Provider Demographics
NPI:1184629552
Name:KOH, ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:KOH
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 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8300
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:1100 W HIGH ST
Practice Address - Street 2:
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931-1706
Practice Address - Country:US
Practice Address - Phone:814-472-7933
Practice Address - Fax:814-472-2301
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052898L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014671780003Medicaid
F82391Medicare UPIN
PA0014671780003Medicaid