Provider Demographics
NPI:1447275748
Name:KOCH, JACK A (DPM)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:KOCH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 CARDAMON LN
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4307
Mailing Address - Country:US
Mailing Address - Phone:714-990-9153
Mailing Address - Fax:714-990-9154
Practice Address - Street 1:425 W BONITA AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:714-990-9153
Practice Address - Fax:714-990-9154
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2255213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E22551Medicaid
CA480005415OtherRAILROAD
CAE2255AMedicare ID - Type Unspecified
CA000E22550Medicare ID - Type Unspecified
CA000E22551Medicaid