Paul Erwin Koch, O.D.
Individual provider Active NPI Optometrist · Ponderay, ID
NPI 1124060041 · NPPES record last updated Apr 14, 2009
Key facts
- NPI
- 1124060041
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- ODP-1026 (ID)
- Practice address
- 476999 Highway 95
Ponderay, ID 83852-9738 - Phone
- (208) 255-5513
- Fax
- (208) 255-5823
- NPI assigned
- Jun 12, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jul 1, 2022 through Jul 1, 2028
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | ODP-1026 | ID | Yes |
Addresses
Primary practice location
476999 Highway 95
Ponderay, ID 83852-9738
Mailing address
1455 Janish Dr
Sandpoint, ID 83864-6244
Phone (208) 255-4801
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 806343800 | Medicaid | ID |
Other providers in Ponderay, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 14, 2009. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Opt Out Affidavits (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.