Healthcare Provider Details

I. General information

NPI: 1184112112
Provider Name (Legal Business Name): SEAN KOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 08/08/2023
Certification Date: 08/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 FALLS BLVD N
WYNNE AR
72396-4027
US

IV. Provider business mailing address

924 AR-77
MARION AR
72364
US

V. Phone/Fax

Practice location:
  • Phone: 870-587-0800
  • Fax:
Mailing address:
  • Phone: 870-739-8670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-15515
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: