Provider Demographics
NPI:1285675967
Name:KOEPSELL, JAMES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVID
Last Name:KOEPSELL
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 1:2829 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-3542
Mailing Address - Country:US
Mailing Address - Phone:815-963-0633
Mailing Address - Fax:
Practice Address - Street 1:2829 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-3542
Practice Address - Country:US
Practice Address - Phone:815-962-0633
Practice Address - Fax:815-962-0142
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077059207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077059Medicaid
IL209203Medicare PIN
IL036077059Medicaid