Provider Demographics
NPI:1972998417
Name:KOCH, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 HUDSON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5849
Mailing Address - Country:US
Mailing Address - Phone:925-595-1994
Mailing Address - Fax:
Practice Address - Street 1:1 BAY ST
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1505
Practice Address - Country:US
Practice Address - Phone:925-595-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10240700207P00000X
CAA149062207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program