Provider Demographics
NPI:1720392392
Name:KOECK, SHIRLEY OGA (OD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:OGA
Last Name:KOECK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 JEAN PL
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-4510
Mailing Address - Country:US
Mailing Address - Phone:818-321-6608
Mailing Address - Fax:
Practice Address - Street 1:69630 STIRLING BLVD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4620
Practice Address - Country:US
Practice Address - Phone:985-327-6258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1621-654T152W00000X
PAOEG002390152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty