Provider Demographics
NPI:1184836447
Name:KOEPKE, ALLISON MARIE LAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:MARIE LAKE
Last Name:KOEPKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ALLISON
Other - Middle Name:MARIE
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8851 SOUTHPOINTE DRIVE
Mailing Address - Street 2:STE C-1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-0805
Mailing Address - Country:US
Mailing Address - Phone:317-887-3344
Mailing Address - Fax:317-885-5018
Practice Address - Street 1:8851 SOUTHPOINTE DRIVE
Practice Address - Street 2:STE C-1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0805
Practice Address - Country:US
Practice Address - Phone:317-887-3344
Practice Address - Fax:317-885-5018
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063739A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200864200Medicaid