Provider Demographics
NPI:1689849549
Name:DANIEL J. KOCH, O.D., LLC
Entity Type:Organization
Organization Name:DANIEL J. KOCH, O.D., LLC
Other - Org Name:COLUMBUS EYEWORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-244-3000
Mailing Address - Street 1:1127 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2441
Mailing Address - Country:US
Mailing Address - Phone:614-421-2020
Mailing Address - Fax:614-421-9115
Practice Address - Street 1:25 W HUBBARD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1410
Practice Address - Country:US
Practice Address - Phone:614-421-2020
Practice Address - Fax:614-421-9115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3759/T520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1669545042OtherINDIVIDUAL NPI (TYPE 1) FOR DANIEL J. KOCH, O.D.
OH293522321008OtherMEDICAL MUTUAL OF OHIO PIN
OH000000134652OtherBLUE CROSS/BLUE SHIELD PIN
OH4628497OtherAETNA PIN
OH821114Medicaid
OH293522321008OtherMEDICAL MUTUAL OF OHIO PIN
OH821114Medicaid