Provider Demographics
NPI:1316149925
Name:KOCH, CODY A (MD, PHD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:A
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 MILLS CIVIC PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-5268
Mailing Address - Country:US
Mailing Address - Phone:515-277-5555
Mailing Address - Fax:
Practice Address - Street 1:4855 MILLS CIVIC PKWY
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-5268
Practice Address - Country:US
Practice Address - Phone:515-277-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2014-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA408142082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1316149925Medicaid
WA0293193OtherL&I