Provider Demographics
NPI:1962497974
Name:KOCH, ROBERT J (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:KOCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1870 W WINCHESTER RD STE 241
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5360
Mailing Address - Country:US
Mailing Address - Phone:847-549-0170
Mailing Address - Fax:847-549-0172
Practice Address - Street 1:1870 W WINCHESTER RD STE 241
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5360
Practice Address - Country:US
Practice Address - Phone:847-549-0170
Practice Address - Fax:847-549-0172
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085152207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085152Medicaid
IL1456310OtherMPIN
IL5031191OtherAETNA
IL1456310OtherMPIN
G29355Medicare UPIN