Provider Demographics
NPI:1245256148
Name:KOCH, DIANE (PT)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 HOSPITAL RD
Mailing Address - Street 2:SUITE 606
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3509
Mailing Address - Country:US
Mailing Address - Phone:949-650-3870
Mailing Address - Fax:949-650-2544
Practice Address - Street 1:351 HOSPITAL RD
Practice Address - Street 2:SUITE 606
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3509
Practice Address - Country:US
Practice Address - Phone:949-650-3870
Practice Address - Fax:949-650-2544
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT99972251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT9997Medicare ID - Type Unspecified