Healthcare Provider Details

I. General information

NPI: 1831185248
Provider Name (Legal Business Name): MAUKS KOEPKE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 NORTH ST SUITE # 309-310
DANBURY CT
06810-5660
US

IV. Provider business mailing address

57 NORTH ST SUITE # 309-310
DANBURY CT
06810-5660
US

V. Phone/Fax

Practice location:
  • Phone: 203-794-0761
  • Fax: 203-731-5399
Mailing address:
  • Phone: 203-794-0761
  • Fax: 203-731-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateCT

VIII. Authorized Official

Name: MRS. KATHERINE ROY
Title or Position: OFFICE MANAGER
Credential: BBA, MBA
Phone: 203-743-4168