Provider Demographics
NPI:1861718587
Name:KOCH, JUSTIN THOMAS (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:KOCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-2450
Mailing Address - Fax:717-851-3469
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-2450
Practice Address - Fax:717-851-3469
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH74630207P00000X
PAOS016603207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102838415Medicaid
PA2899302OtherHIGHMARK BLUE SHIELD
PA2899302OtherHIGHMARK BLUE SHIELD