Provider Demographics
NPI:1417958372
Name:KOH, EDWARD T (MD PHD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:T
Last Name:KOH
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 WAVERLEY OAKS RD
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-9418
Mailing Address - Country:US
Mailing Address - Phone:781-891-3510
Mailing Address - Fax:
Practice Address - Street 1:300 GROVE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3908
Practice Address - Country:US
Practice Address - Phone:781-864-7217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52523207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB74509Medicare UPIN
MAJ03727Medicare ID - Type Unspecified