Provider Demographics
NPI:1053440008
Name:TAGLE, LAURA KOEPPEL (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KOEPPEL
Last Name:TAGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FOXFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-208-3200
Mailing Address - Fax:630-208-3201
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-208-3200
Practice Address - Fax:630-208-3201
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00673207R00000X
IL036138795207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0067FMedicaid
NC1053440008Medicaid
IL920540OtherMEDICARE PTAN - GROUP
NC5909695Medicaid
ILF400237969OtherMEDICARE PTAN - INDIVIDUAL
NC2022405AMedicare PIN
NC2022405Medicare PIN
ILF400237969OtherMEDICARE PTAN - INDIVIDUAL