Provider Demographics
NPI:1144258666
Name:KOCH, SANDRA JEAN (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
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 1:233 VALLEYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-8136
Mailing Address - Country:US
Mailing Address - Phone:580-529-2355
Mailing Address - Fax:
Practice Address - Street 1:233 VALLEYVIEW DR
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-8136
Practice Address - Country:US
Practice Address - Phone:580-529-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3528208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
D34906Medicare UPIN