Provider Demographics
NPI:1528228319
Name:KOCH, LAINE K (MD)
Entity type:Individual
Prefix:
First Name:LAINE
Middle Name:K
Last Name:KOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 KEMPSVILLE CIR STE 200A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3945
Mailing Address - Country:US
Mailing Address - Phone:757-622-6315
Mailing Address - Fax:757-622-7022
Practice Address - Street 1:11842 ROCK LANDING DR STE 120
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4437
Practice Address - Country:US
Practice Address - Phone:757-622-6315
Practice Address - Fax:757-622-7022
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101257007207N00000X
VA0116017371390200000X
MA244641207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFN153ZMedicare PIN
CACA175393Medicare PIN