Basic Information
| Provider Information | |||||||||
| NPI: | 1386664928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOCH | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 EL DORADO CT | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956955218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306620354 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1207 FAIRCHILD CT | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956954321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306661631 | ||||||||
| FaxNumber: | 5306612410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | G36013 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00G360130 | 01 | CA | BLUE SHIELD | OTHER | 00G360130 | 05 | CA | MEDICAID |