Healthcare Provider Details

I. General information

NPI: 1790781615
Provider Name (Legal Business Name): ROBERT KOORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 03/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 OLD REDDING RD
REDDING CT
06896-2201
US

IV. Provider business mailing address

10 OLD REDDING RD
REDDING CT
06896-2201
US

V. Phone/Fax

Practice location:
  • Phone: 203-224-3081
  • Fax:
Mailing address:
  • Phone: 203-224-3081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number200917-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number044260
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5888390-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: