Provider Demographics
NPI:1568857316
Name:KOCH, KIRSTEN (MD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:
Other - Last Name:LANGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3805 EDWARDS RD STE 360
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-1934
Mailing Address - Country:US
Mailing Address - Phone:513-871-7848
Mailing Address - Fax:513-871-3278
Practice Address - Street 1:3805 EDWARDS RD STE 360
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209
Practice Address - Country:US
Practice Address - Phone:513-871-7848
Practice Address - Fax:513-871-3278
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-133807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100537860Medicaid
OH0288732Medicaid