Provider Demographics
NPI:1124110002
Name:KOTH, JOHN C (MPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:KOTH
Suffix:
Gender:M
Credentials:MPT
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 1510
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-1510
Mailing Address - Country:US
Mailing Address - Phone:208-788-3997
Mailing Address - Fax:208-726-1607
Practice Address - Street 1:101 SADDLE ROAD
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-1510
Practice Address - Country:US
Practice Address - Phone:208-726-9222
Practice Address - Fax:208-726-1607
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT614225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1655004Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE