Provider Demographics
NPI:1841202017
Name:KOCH, FRED DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:DANIEL
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL WAY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2166
Mailing Address - Country:US
Mailing Address - Phone:770-979-9903
Mailing Address - Fax:770-979-7312
Practice Address - Street 1:1600 MEDICAL WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2166
Practice Address - Country:US
Practice Address - Phone:770-979-9903
Practice Address - Fax:770-979-7312
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052122207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000982132CMedicaid
GA000982132DMedicaid
GA000982132EMedicaid
GA000982132DMedicaid
GA20NCCPPMedicare PIN