Healthcare Provider Details

I. General information

NPI: 1508216920
Provider Name (Legal Business Name): DAVID KOCH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DRIVE, DC06910
COLUMBIA MO
65212
US

IV. Provider business mailing address

1 HOSPITAL DRIVE, DC06910
COLUMBIA MO
65212
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-1026
  • Fax: 573-884-8524
Mailing address:
  • Phone: 573-882-1026
  • Fax: 573-884-8524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2016017560
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2016017560
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: