Provider Demographics
NPI:1083631014
Name:PROKOP, OTO (MD)
Entity Type:Individual
Prefix:
First Name:OTO
Middle Name:
Last Name:PROKOP
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:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-474-0905
Mailing Address - Fax:207-474-6930
Practice Address - Street 1:46 FAIRVIEW AVE STE 111
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1481
Practice Address - Country:US
Practice Address - Phone:207-474-0905
Practice Address - Fax:207-474-6930
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15742207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1083631014Medicaid
ME339270099Medicaid
ME339270099Medicaid