Provider Demographics
NPI:1093716532
Name:REPKE, CAROLYN S (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:S
Last Name:REPKE
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 1:1930 S BROAD ST UNIT 9
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-2328
Mailing Address - Country:US
Mailing Address - Phone:215-339-8100
Mailing Address - Fax:215-339-8103
Practice Address - Street 1:1930 S BROAD ST UNIT 9
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-339-8100
Practice Address - Fax:215-339-8103
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051481L207WX0200X, 207W00000X
NJ25MA06190700207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0161265Medicaid
PA761199EVTMedicare PIN
PA0161265Medicaid