Provider Demographics
NPI:1649452707
Name:KOCH, MAX W
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:W
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 1:603 BISCAYNE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3235
Mailing Address - Country:US
Mailing Address - Phone:817-909-6293
Mailing Address - Fax:866-409-0273
Practice Address - Street 1:400 INDUSTRIAL BLVD
Practice Address - Street 2:STE 108
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2202
Practice Address - Country:US
Practice Address - Phone:817-453-2800
Practice Address - Fax:866-409-0273
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4285100001Medicare NSC