Healthcare Provider Details

I. General information

NPI: 1386348084
Provider Name (Legal Business Name): IAN MICHAEL KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S ANDREWS AVE
FORT LAUDERDALE FL
33316-2510
US

IV. Provider business mailing address

10515 N HADDONSTONE PL
MEQUON WI
53092-5953
US

V. Phone/Fax

Practice location:
  • Phone: 954-335-4400
  • Fax:
Mailing address:
  • Phone: 262-389-7917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: