Provider Demographics
NPI:1649346073
Name:KOCH, PAUL DAVID (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5374 MOONLITE DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8794
Mailing Address - Country:US
Mailing Address - Phone:920-983-0116
Mailing Address - Fax:920-884-3271
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-593-3938
Practice Address - Fax:920-884-3271
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI20415-020207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30980400Medicaid
WI30980400Medicaid
MIM84790003Medicare ID - Type Unspecified