Provider Demographics
NPI:1518904515
Name:KOCH, SHERRI DANELLE (MD)
Entity Type:Individual
Prefix:
First Name:SHERRI
Middle Name:DANELLE
Last Name:KOCH
Suffix:
Gender:F
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:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-0346
Mailing Address - Country:US
Mailing Address - Phone:605-721-6426
Mailing Address - Fax:605-721-5515
Practice Address - Street 1:4447 S CANYON RD
Practice Address - Street 2:SUITE 6
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-1807
Practice Address - Country:US
Practice Address - Phone:605-721-6426
Practice Address - Fax:605-721-5515
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28953207Q00000X
SD4447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5620280Medicaid
SDS105195OtherMEDICARE PTAN
AZ738891Medicaid
SDS105195OtherMEDICARE PTAN