Provider Demographics
NPI:1669545042
Name:KOCH, DANIEL JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
Last Name:KOCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W HUBBARD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1410
Mailing Address - Country:US
Mailing Address - Phone:614-421-2020
Mailing Address - Fax:614-421-9115
Practice Address - Street 1:25 W HUBBARD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1410
Practice Address - Country:US
Practice Address - Phone:614-421-2020
Practice Address - Fax:614-421-9115
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3759T520152W00000X
CO1226152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4628497OtherAETNA PROVIDER ID #
OH1325654OtherWORKERS' COMP. RISK #
OH34-1585183-00OtherBWC PROVIDER NUMBER
OH000000134652OtherANTHEM BC PROVIDER ID #
OH0821114Medicaid
OH34-1585183OtherFEDERAL TAX ID #
OH1325654OtherWORKERS' COMP. RISK #
OH34-1585183-00OtherBWC PROVIDER NUMBER