Provider Demographics
NPI:1477524957
Name:KOEPKE, JERALD WALTER (MD)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:WALTER
Last Name:KOEPKE
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 1:125 RAMPART WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-6429
Mailing Address - Country:US
Mailing Address - Phone:720-858-7550
Mailing Address - Fax:720-858-7615
Practice Address - Street 1:9331 S COLORADO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80126-7465
Practice Address - Country:US
Practice Address - Phone:303-795-8177
Practice Address - Fax:303-797-2166
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0020778207K00000X
CO20778174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01207760Medicaid
CO01207760Medicaid
COC19514Medicare PIN