Provider Demographics
NPI:1174512651
Name:KOCH, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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:PO BOX 911294
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1294
Mailing Address - Country:US
Mailing Address - Phone:817-852-8440
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:DEPT OF FAMILY MEDICINE
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-927-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX489552ZUHKMedicare PIN
TXG16049Medicare UPIN