Healthcare Provider Details

I. General information

NPI: 1255223640
Provider Name (Legal Business Name): MATTHEW JOSEPH KOCH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N MAYFAIR RD FL 1
WAUWATOSA WI
53226-4216
US

IV. Provider business mailing address

5048 MICHIGAN AVE
MANITOWOC WI
54220-9428
US

V. Phone/Fax

Practice location:
  • Phone: 414-259-7292
  • Fax: 414-259-7515
Mailing address:
  • Phone: 920-323-9581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: