Provider Demographics
NPI:1225303415
Name:KOCH, IAN (DO)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
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:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:515-875-9923
Practice Address - Street 1:5950 UNIVERSITY AVE STE 145
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8233
Practice Address - Country:US
Practice Address - Phone:515-875-9740
Practice Address - Fax:515-875-9672
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN616382085R0202X
IADO-051192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program