Individual
ETHAN BENJAMIN KOCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4801 VETERANS DR, SAINT CLOUD, MN 56303-2015
(320) 252-1670
Mailing address
4801 VETERANS DR, SAINT CLOUD, MN 56303-2015
(320) 252-1670
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
71757
MN
208D00000X
General Practice Physician
71757
MN
208VP0000X
Pain Medicine Physician
Primary
71757
MN
Other
Enumeration date
03/30/2018
Last updated
04/03/2025
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