Healthcare Provider Details

I. General information

NPI: 1275143075
Provider Name (Legal Business Name): AVA LOUISE KOCH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 OLD COUNTRY RD STE G-KL
RIVERHEAD NY
11901-2115
US

IV. Provider business mailing address

44 ROOSEVELT ST
GLEN HEAD NY
11545-1422
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-2858
  • Fax:
Mailing address:
  • Phone: 516-236-8538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number009217
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: