Healthcare Provider Details

I. General information

NPI: 1447275748
Provider Name (Legal Business Name): JACK A KOCH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W BONITA AVE STE 110
SAN DIMAS CA
91773-2543
US

IV. Provider business mailing address

2937 CARDAMON LN
FULLERTON CA
92835-4307
US

V. Phone/Fax

Practice location:
  • Phone: 714-990-9153
  • Fax: 714-990-9154
Mailing address:
  • Phone: 714-990-9153
  • Fax: 714-990-9154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE2255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: