Healthcare Provider Details

I. General information

NPI: 1023673712
Provider Name (Legal Business Name): JACLYN ALEKSANDRA KONOPKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SAYBROOK RD STE 100
MIDDLETOWN CT
06457-4788
US

IV. Provider business mailing address

5 HIGH RIDGE PARK FL 2
STAMFORD CT
06905-1332
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-7636
  • Fax: 860-894-1894
Mailing address:
  • Phone: 203-869-1145
  • Fax: 203-618-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number13867906-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number80749
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number13867906-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: