Healthcare Provider Details

I. General information

NPI: 1104824044
Provider Name (Legal Business Name): JOHN KEVIN KOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 GRAND CENTRAL MALL SUITE 2
VIENNA WV
26105-4100
US

IV. Provider business mailing address

800 GRAND CENTRAL MALL SUITE 2
VIENNA WV
26105-4100
US

V. Phone/Fax

Practice location:
  • Phone: 304-865-4350
  • Fax: 304-865-4348
Mailing address:
  • Phone: 304-865-4350
  • Fax: 304-865-4348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number19553
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: