Provider Demographics
NPI:1255574711
Name:DR. PAUL E. KOCH, OPTOMETRIST, P.C
Entity type:Organization
Organization Name:DR. PAUL E. KOCH, OPTOMETRIST, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ERWIN
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-290-2401
Mailing Address - Street 1:476999 HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-9738
Mailing Address - Country:US
Mailing Address - Phone:208-255-5513
Mailing Address - Fax:208-255-5823
Practice Address - Street 1:476999 HIGHWAY 95
Practice Address - Street 2:C/O WALMART VISION CENTER
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9738
Practice Address - Country:US
Practice Address - Phone:208-255-5513
Practice Address - Fax:208-255-5823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP1026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806343800Medicaid
ID806343800Medicaid
ID1593991Medicare PIN