Healthcare Provider Details

I. General information

NPI: 1952006439
Provider Name (Legal Business Name): AIDAN KOCH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 E STOP 11 RD STE 250
INDIANAPOLIS IN
46237-6399
US

IV. Provider business mailing address

PO BOX 781008
DETROIT MI
48278-1008
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-8921
  • Fax: 317-528-6916
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

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: