Provider Demographics
NPI:1598796393
Name:KOCH, ERICKA (OD)
Entity Type:Individual
Prefix:
First Name:ERICKA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 BANDANA BLVD E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5113
Mailing Address - Country:US
Mailing Address - Phone:651-642-2700
Mailing Address - Fax:
Practice Address - Street 1:3024 SNELLING AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1911
Practice Address - Country:US
Practice Address - Phone:612-775-4900
Practice Address - Fax:612-721-1621
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN524113800Medicaid
MN524113800Medicaid
MN410003605Medicare PIN