Healthcare Provider Details

I. General information

NPI: 1053373456
Provider Name (Legal Business Name): ERIC J KOCH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 SPINDRIFT DR
WILLIAMSVILLE NY
14221
US

IV. Provider business mailing address

297 SPINDRIFT DR
WILLIAMSVILLE NY
14221
US

V. Phone/Fax

Practice location:
  • Phone: 716-635-0688
  • Fax: 716-635-0151
Mailing address:
  • Phone: 716-635-0688
  • Fax: 716-635-0151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number229921
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: