Provider Demographics
NPI:1487651303
Name:KOCH, BRENTON B (MD)
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:B
Last Name:KOCH
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 1:4855 MILLS CIVIC PKWY # 100
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-5268
Mailing Address - Country:US
Mailing Address - Phone:515-277-5555
Mailing Address - Fax:515-277-0060
Practice Address - Street 1:4855 MILLS CIVIC PKWY # 100
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-5268
Practice Address - Country:US
Practice Address - Phone:515-277-5555
Practice Address - Fax:515-277-0060
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31968207YS0123X, 207YX0905X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1162586Medicaid
IAI3915Medicare ID - Type Unspecified
IA1162586Medicaid