Provider Demographics
NPI:1518951193
Name:KOEPKE, CHARLES ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
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 1:1440 ROCKSIDE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-2749
Mailing Address - Country:US
Mailing Address - Phone:216-749-8276
Mailing Address - Fax:216-749-8240
Practice Address - Street 1:1440 ROCKSIDE RD STE 202
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134
Practice Address - Country:US
Practice Address - Phone:216-749-8276
Practice Address - Fax:216-749-8240
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076187207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH110201424OtherRAILROAD MEDICARE
OH393446OtherWELLCARE OF OH
OH000000184421OtherUNICARE- LIFE AND HEALTH
OH2167542Medicaid
OHP76187OtherSUMMACARE HEALTH PLAN
OH000000184421OtherANTHEM
OH341847368033OtherCARESOURCE
OH000000184421OtherUNICARE- LIFE AND HEALTH
OH341847368033OtherCARESOURCE
OH110201424Medicare PIN