Healthcare Provider Details

I. General information

NPI: 1114036829
Provider Name (Legal Business Name): DONALD F KOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 04/22/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W DELAWARE PL
CHICAGO IL
60610-8115
US

IV. Provider business mailing address

176 SPRING LAKE CIR
NAPLES FL
34119-4678
US

V. Phone/Fax

Practice location:
  • Phone: 708-386-6565
  • Fax: 708-386-6589
Mailing address:
  • Phone: 708-638-1229
  • Fax: 239-304-3681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036040159
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: