Provider Demographics
NPI:1871570127
Name:KOCH, THOMAS JACOB (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JACOB
Last Name:KOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 W JONATHAN ST
Mailing Address - Street 2:STE 100
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-3170
Mailing Address - Country:US
Mailing Address - Phone:610-628-1225
Mailing Address - Fax:610-628-1132
Practice Address - Street 1:1728 W JONATHAN ST
Practice Address - Street 2:STE 100
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-3170
Practice Address - Country:US
Practice Address - Phone:610-628-1225
Practice Address - Fax:610-628-1132
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038042E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC32702Medicare UPIN