Provider Demographics
NPI:1063722866
Name:KOCH, KORBIN JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:KORBIN
Middle Name:JAMES
Last Name:KOCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7428
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97602-0428
Mailing Address - Country:US
Mailing Address - Phone:541-885-5405
Mailing Address - Fax:541-883-1158
Practice Address - Street 1:3600 WASHBURN WAY
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4539
Practice Address - Country:US
Practice Address - Phone:541-885-5405
Practice Address - Fax:541-883-1158
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3495ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R174660Medicare PIN