Basic Information
| Provider Information | |||||||||
| NPI: | 1366479875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROKOPOVA | ||||||||
| FirstName: | KATARINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1599 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044021599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079455247 | ||||||||
| FaxNumber: | 2079470435 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 BRUNSWICK ST | ||||||||
| Address2: | |||||||||
| City: | OLD TOWN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044681613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078276128 | ||||||||
| FaxNumber: | 2078276605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD16221 | ME | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 305150099 | 05 | ME | MEDICAID |