Healthcare Provider Details

I. General information

NPI: 1639233075
Provider Name (Legal Business Name): DAVID A. KOCH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

858 E WELSH RD SUITE 12
MAPLE GLEN PA
19002-2942
US

IV. Provider business mailing address

858 E WELSH RD SUITE 12
MAPLE GLEN PA
19002-2942
US

V. Phone/Fax

Practice location:
  • Phone: 215-542-0460
  • Fax: 215-542-9058
Mailing address:
  • Phone: 215-542-0460
  • Fax: 215-542-9058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000662
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: