Healthcare Provider Details

I. General information

NPI: 1649255845
Provider Name (Legal Business Name): ROBERT B KOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

IV. Provider business mailing address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

V. Phone/Fax

Practice location:
  • Phone: 707-393-4080
  • Fax:
Mailing address:
  • Phone: 707-393-4080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberC134952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: