Healthcare Provider Details

I. General information

NPI: 1144258666
Provider Name (Legal Business Name): SANDRA JEAN KOCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 VALLEYVIEW DR
LAWTON OK
73507-8136
US

IV. Provider business mailing address

233 VALLEYVIEW DR
LAWTON OK
73507-8136
US

V. Phone/Fax

Practice location:
  • Phone: 580-529-2355
  • Fax:
Mailing address:
  • Phone: 580-529-2355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG3528
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: