1053389858 NPI number — DR. RONALD PAUL KOEPKE M.D.

Table of content: DR. RONALD PAUL KOEPKE M.D. (NPI 1053389858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053389858 NPI number — DR. RONALD PAUL KOEPKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOEPKE
Provider First Name:
RONALD
Provider Middle Name:
PAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053389858
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 DESIARD ST
Provider Second Line Business Mailing Address:
SUITE 355
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-7319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-807-7875
Provider Business Mailing Address Fax Number:
318-812-6603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2516 BROADMOOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-2988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-322-1161
Provider Business Practice Location Address Fax Number:
318-322-9313
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  012929 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100471 . This is a "VANTAGE HEALTH PLAN, INC" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1191469 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012929 . This is a "LOUISIANA GROUP" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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