Healthcare Provider Details

I. General information

NPI: 1063722866
Provider Name (Legal Business Name): KORBIN JAMES KOCH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 WASHBURN WAY WALMART VISION CENTER
KLAMATH FALLS OR
97603-4539
US

IV. Provider business mailing address

PO BOX 7428
KLAMATH FALLS OR
97602-0428
US

V. Phone/Fax

Practice location:
  • Phone: 541-885-5405
  • Fax: 541-883-1158
Mailing address:
  • Phone: 541-885-5405
  • Fax: 541-883-1158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3495ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: