Provider Demographics
NPI:1649430208
Name:KOCH, REGINA MARIE (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:KOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:MARIE
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:55 LAKE AVE N
Mailing Address - Street 2:RADIOLOGY DEPT
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:508-368-0000
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2465562085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA246556Other1649430208
AZR70177OtherTRAINING PERMIT