Provider Demographics
NPI:1639233075
Name:KOCH, DAVID A (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:KOCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:858 E WELSH RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MAPLE GLEN
Mailing Address - State:PA
Mailing Address - Zip Code:19002-2942
Mailing Address - Country:US
Mailing Address - Phone:215-542-0460
Mailing Address - Fax:215-542-9058
Practice Address - Street 1:858 E WELSH RD
Practice Address - Street 2:SUITE 12
Practice Address - City:MAPLE GLEN
Practice Address - State:PA
Practice Address - Zip Code:19002-2942
Practice Address - Country:US
Practice Address - Phone:215-542-0460
Practice Address - Fax:215-542-9058
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOEG000662152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU08380Medicare UPIN
PA285209Medicare PIN
PA0396070001Medicare NSC