Provider Demographics
NPI:1053637561
Name:KOPPENHEFFER, PETER BROOKS (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:BROOKS
Last Name:KOPPENHEFFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1619
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:48 SANDERSON ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301
Practice Address - Country:US
Practice Address - Phone:413-773-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269392207Q00000X
MA275445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine