Provider Demographics
NPI:1336169226
Name:KOCH, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 1:222 S 1ST ST
Mailing Address - Street 2:SUITE 501
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5404
Mailing Address - Country:US
Mailing Address - Phone:502-583-2731
Mailing Address - Fax:502-583-2733
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1818
Practice Address - Country:US
Practice Address - Phone:502-583-2731
Practice Address - Fax:502-583-2733
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY341662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1072012Medicaid
KY64341662Medicaid
KY000000062495OtherANTHEM BLUE FACET
OH2564818Medicaid
WV7200237000Medicaid
WV7200237000Medicaid
KY1279216Medicare ID - Type Unspecified
KY64341662Medicaid