Provider Demographics
NPI:1871665182
Name:KOCH, KENNETH LYLE (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LYLE
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 1:124 E ROWAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1214
Mailing Address - Country:US
Mailing Address - Phone:509-484-6550
Mailing Address - Fax:
Practice Address - Street 1:124 E ROWAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1214
Practice Address - Country:US
Practice Address - Phone:509-484-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0301980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021509Medicaid
WA25685OtherL & I
WA2021509Medicaid