Healthcare Provider Details

I. General information

NPI: 1124060041
Provider Name (Legal Business Name): PAUL ERWIN KOCH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476999 HIGHWAY 95
PONDERAY ID
83852-9738
US

IV. Provider business mailing address

1455 JANISH DR
SANDPOINT ID
83864-6244
US

V. Phone/Fax

Practice location:
  • Phone: 208-255-5513
  • Fax: 208-255-5823
Mailing address:
  • Phone: 208-255-4801
  • Fax: 208-255-5823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-1026
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: