Provider Demographics
NPI:1609833730
Name:KOOBATIAN, GREGOR J (MD)
Entity Type:Individual
Prefix:
First Name:GREGOR
Middle Name:J
Last Name:KOOBATIAN
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 1:410 SAYBROOK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-4620
Mailing Address - Fax:860-346-9687
Practice Address - Street 1:410 SAYBROOK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-4620
Practice Address - Fax:860-346-9687
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT038341207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001383413Medicaid
CT001383413Medicaid
G16945Medicare UPIN