Provider Demographics
NPI:1912092693
Name:KOCH, SUSAN ELISE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELISE
Last Name:KOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:ELISE
Other - Last Name:JAHNKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20200 SE WALGREN RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089
Mailing Address - Country:US
Mailing Address - Phone:503-658-7218
Mailing Address - Fax:
Practice Address - Street 1:9900 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9750
Practice Address - Country:US
Practice Address - Phone:503-653-6440
Practice Address - Fax:503-571-8974
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21378207N00000X
WAMD00037941207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology