Provider Demographics
NPI:1497784847
Name:KOCH, TIMOTHY C (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
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 1:2414 KOHLER MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3129
Mailing Address - Country:US
Mailing Address - Phone:920-457-4461
Mailing Address - Fax:
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43215-21207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI930105103OtherMEDICARE RAILROAD
WI43492500Medicaid
WI0084-68655Medicare ID - Type Unspecified
G84963Medicare UPIN
WI43492500Medicaid