MEDICARE: DR. GREGORY ERNEST KOCH PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	PSY19917	CA
2	103TC0700X	Clinical Psychologist	PSY19917	CA
3	103TC2200X	Clinical Child & Adolescent Psychologist	PSY19917	CA
4	103T00000X	Psychologist	PSY19917	CA
5	103TP2701X	Group Psychotherapy Psychologist	PSY19917	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0PL199170	OTHER	CA	BLUE SHIELD
2	11397904	OTHER	CA	CAQH
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	5551998	OTHER	CA	FIRSTHEALTH/CCN

General Provider Information

NPI Number	:	1730180852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY ERNEST KOCH PSY.D.

Provider Business Mailing Address
First Line	:	4081 STEPHENS ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1242
Country	:	US
Telephone Number	:	888-588-7836
Fax Number	:	888-588-7836

Provider Business Practice Location Address
First Line	:	4081 STEPHENS ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1242
Country	:	US
Telephone Number	:	888-588-7836
Fax Number	:	888-588-7836

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	09/11/2025

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