Bruce M Koch, OD
Individual provider Active NPI Optometrist · Prairie Du Sac, WI
NPI 1720031529 · NPPES record last updated Apr 11, 2011
Key facts
- NPI
- 1720031529
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- 1322-035 (WI)
- Practice address
- 1110 Prairie St
Prairie Du Sac, WI 53578-2044 - Phone
- (608) 643-3333
- Fax
- (608) 644-3852
- NPI assigned
- May 19, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1322 | WI | MD | Clinical Social Worker |
| 1322-035 | WI | MD | Optometrist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 1322-035 | WI | Yes |
Addresses
Primary practice location
1110 Prairie St
Prairie Du Sac, WI 53578-2044
Mailing address
1110 Prairie St
Prairie Du Sac, WI 53578-2044
Phone (608) 643-3333
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 38567400 | Medicaid | WI | |
| 1006588 | Other | WI | PHYSICIANS PLUS |
| 947 | Other | WI | DEAN HEALTH INSURANCE |
Other providers in Prairie Du Sac, WI
- Julie A Kastelitz
- Bryant Randall Kearney
- Holly J Kindschi
- Lori E King
- Breana Kirch
- Kristin Kolodziej
- Carly Marie Kraemer
- Alicia C Krizan
- Brieanne M Laberge
- Yuen Sim Lai
All providers in Prairie Du Sac, WI · Optometrist in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 11, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.