Provider Demographics
NPI:1013177211
Name:KOCH, JAMIE C (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:C
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:PO BOX 1386A
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74821-4913
Mailing Address - Country:US
Mailing Address - Phone:405-200-7696
Mailing Address - Fax:580-332-5750
Practice Address - Street 1:430 N MONTE VISTA ST
Practice Address - Street 2:OK
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4610
Practice Address - Country:US
Practice Address - Phone:580-421-1160
Practice Address - Fax:580-332-5750
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26420207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology