Basic Information
| Provider Information | |||||||||
| NPI: | 1245455740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOPEC | ||||||||
| FirstName: | KRZYSZTOF | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2139 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | ROCKY HILL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060672336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602574131 | ||||||||
| FaxNumber: | 8602574519 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 SOUTH RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060322482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604094567 | ||||||||
| FaxNumber: | 8604094846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 08/09/2012 | ||||||||
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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 | 207R00000X | LP00875 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 050994 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 008040556 | 05 | CT | MEDICAID |