Provider Demographics
NPI:1649204058
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:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N HYATT ST
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1434
Mailing Address - Country:US
Mailing Address - Phone:937-667-6914
Mailing Address - Fax:937-667-3744
Practice Address - Street 1:410 N HYATT ST
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1434
Practice Address - Country:US
Practice Address - Phone:937-667-6914
Practice Address - Fax:937-667-3744
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHT1099/3544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000018967OtherANTHEM
OH311441019OtherAETNA TAX ID NUMBER
OH4248731Medicare PIN
OH000000018967OtherANTHEM