Provider Demographics
NPI:1811166135
Name:DAVID A. KOCH, O.D., INC.
Entity type:Organization
Organization Name:DAVID A. KOCH, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-667-6914
Mailing Address - Street 1:410 N HYATT ST
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1434
Mailing Address - Country:US
Mailing Address - Phone:937-667-6914
Mailing Address - Fax:937-667-3744
Practice Address - Street 1:410 N HYATT ST
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1434
Practice Address - Country:US
Practice Address - Phone:937-667-6914
Practice Address - Fax:937-667-3744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH55031434332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1041160001Medicare NSC
OH0502623Medicare PIN