Provider Demographics
NPI:1801840574
Name:KOCH, DOUGLAS JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
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 1:1100 KINGS HWY E
Mailing Address - Street 2:STE 1C
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-5400
Mailing Address - Country:US
Mailing Address - Phone:203-576-1993
Mailing Address - Fax:203-333-6497
Practice Address - Street 1:1100 KINGS HWY E
Practice Address - Street 2:STE 1C
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-5400
Practice Address - Country:US
Practice Address - Phone:203-576-1993
Practice Address - Fax:203-333-6497
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU29571Medicare UPIN
CT350000675Medicare ID - Type Unspecified