Provider Demographics
NPI:1790781615
Name:KOORN, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KOORN
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 1:10 OLD REDDING RD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CT
Mailing Address - Zip Code:06896-2201
Mailing Address - Country:US
Mailing Address - Phone:203-224-3081
Mailing Address - Fax:
Practice Address - Street 1:10 OLD REDDING RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CT
Practice Address - Zip Code:06896-2201
Practice Address - Country:US
Practice Address - Phone:203-224-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200917-1207L00000X
CT044260207L00000X
UT5888390-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01725644Medicaid
338741Medicare ID - Type Unspecified
NY01725644Medicaid