Provider Demographics
NPI:1972923225
Name:KOCH, TIFFANY TRUONG (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:TRUONG
Last Name:KOCH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-0330
Mailing Address - Country:US
Mailing Address - Phone:317-863-2556
Mailing Address - Fax:317-203-0420
Practice Address - Street 1:7330 E 82ND ST
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1465
Practice Address - Country:US
Practice Address - Phone:317-712-3708
Practice Address - Fax:317-712-3798
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001245B213E00000X
390200000X
IN07001245A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005049Medicaid