Provider Demographics
NPI:1124060041
Name:KOCH, PAUL ERWIN (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ERWIN
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 1:1455 JANISH DR
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-6244
Mailing Address - Country:US
Mailing Address - Phone:208-255-4801
Mailing Address - Fax:208-255-5823
Practice Address - Street 1:476999 HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9738
Practice Address - Country:US
Practice Address - Phone:208-255-5513
Practice Address - Fax:208-255-5823
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-1026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806343800Medicaid
ID1593991Medicare ID - Type Unspecified
IDT48172Medicare UPIN