Provider Demographics
NPI:1699828251
Name:KOCH, MARK JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:KOCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 LEGION DR
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2202
Mailing Address - Country:US
Mailing Address - Phone:262-784-8232
Mailing Address - Fax:262-784-4139
Practice Address - Street 1:1055 LEGION DR
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2202
Practice Address - Country:US
Practice Address - Phone:262-784-8232
Practice Address - Fax:262-784-4139
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3460111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38926800Medicaid
WI38926800Medicaid
WI000035201Medicare PIN