Individual
JACK A KOCH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
425 W BONITA AVE STE 110, SAN DIMAS, CA 91773-2543
(714) 990-9153
(714) 990-9154
Mailing address
2937 CARDAMON LN, FULLERTON, CA 92835-4307
(714) 990-9153
(714) 990-9154
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
E2255
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000E22551
—
CA
01
—
480005415
RAILROAD
CA
Enumeration date
07/13/2006
Last updated
09/26/2017
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