Provider Demographics
NPI:1275630410
Name:KOCH, RUSSELL EUGENE (PHD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EUGENE
Last Name:KOCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 WALL STREET
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069
Mailing Address - Country:US
Mailing Address - Phone:405-928-2044
Mailing Address - Fax:405-928-2049
Practice Address - Street 1:820 WALL ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069
Practice Address - Country:US
Practice Address - Phone:405-928-2044
Practice Address - Fax:405-928-2049
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK602103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100838010AMedicaid