MEDICARE: DAVID A. KOCH, O.D., INC.

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	332H00000X	Eyewear Supplier	55031434	OH
2	152W00000X	Optometrist	55031434	OH

General Provider Information

NPI Number	:	1811166135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID A. KOCH, O.D., INC.

Provider Business Mailing Address
First Line	:	410 N HYATT ST
Second Line	:
City	:	TIPP CITY
State	:	OH
Zip	:	45371-1434
Country	:	US
Telephone Number	:	937-667-6914
Fax Number	:	937-667-3744

Provider Business Practice Location Address
First Line	:	410 N HYATT ST
Second Line	:
City	:	TIPP CITY
State	:	OH
Zip	:	45371-1434
Country	:	US
Telephone Number	:	937-667-6914
Fax Number	:	937-667-3744

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID KOCH
Credential	:	O.D.
Telephone Number	:	937-667-6914

Provider Enumeration Date	:	02/21/2008
Last Update Date	:	06/21/2013

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