Provider Demographics
NPI:1275143075
Name:KOCH, AVA LOUISE (OD)
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:LOUISE
Last Name:KOCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1422
Mailing Address - Country:US
Mailing Address - Phone:516-236-8538
Mailing Address - Fax:
Practice Address - Street 1:887 OLD COUNTRY RD STE G-KL
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2115
Practice Address - Country:US
Practice Address - Phone:631-727-2858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009217152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist