Healthcare Provider Details

I. General information

NPI: 1649346073
Provider Name (Legal Business Name): PAUL DAVID KOCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S VAN BUREN ST
GREEN BAY WI
54301-3526
US

IV. Provider business mailing address

5374 MOONLITE DR
DE PERE WI
54115-8794
US

V. Phone/Fax

Practice location:
  • Phone: 920-593-3938
  • Fax: 920-884-3271
Mailing address:
  • Phone: 920-983-0116
  • Fax: 920-884-3271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number20415-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: