Healthcare Provider Details

I. General information

NPI: 1720031529
Provider Name (Legal Business Name): BRUCE M KOCH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 PRAIRIE ST
PRAIRIE DU SAC WI
53578-2044
US

IV. Provider business mailing address

1110 PRAIRIE ST
PRAIRIE DU SAC WI
53578-2044
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-3333
  • Fax: 608-644-3852
Mailing address:
  • Phone: 608-643-3333
  • Fax: 608-644-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1322-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: