Provider Demographics
NPI:1720031529
Name:KOCH, BRUCE M (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
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 1:1110 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2044
Mailing Address - Country:US
Mailing Address - Phone:608-643-3333
Mailing Address - Fax:608-644-3852
Practice Address - Street 1:1110 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2044
Practice Address - Country:US
Practice Address - Phone:608-643-3333
Practice Address - Fax:608-644-3852
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1322-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38567400Medicaid
WI1006588OtherPHYSICIANS PLUS
WI947OtherDEAN HEALTH INSURANCE
WI947OtherDEAN HEALTH INSURANCE
WI38567400Medicaid
T62451Medicare UPIN