Provider Demographics
NPI:1538138235
Name:KOCH, C W JR (MD)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:W
Last Name:KOCH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 E RACE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4979
Mailing Address - Country:US
Mailing Address - Phone:501-268-5845
Mailing Address - Fax:501-268-7327
Practice Address - Street 1:3130 E RACE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4979
Practice Address - Country:US
Practice Address - Phone:501-268-5845
Practice Address - Fax:501-268-7327
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC4335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106477001Medicaid
ARE24225Medicare UPIN
AR0904380005Medicare NSC
AR52962Medicare PIN
AR106477001Medicaid