Provider Demographics
NPI:1023102084
Name:KOCH, CHRISTIAN E (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:E
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 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3191
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:3080 ACKERMAN BLVD STE 110
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3559
Practice Address - Country:US
Practice Address - Phone:937-293-5080
Practice Address - Fax:937-293-8820
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-075086207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201063420Medicaid
000000770719OtherANTHEM (REID PHYSICIAN ASSOCIATES)
OH2203378Medicaid
OH01-05947OtherUNITED HEALTHCARE
OHK04039411Medicare PIN