Provider Demographics
NPI:1881613198
Name:KONOPACKI, MARIE A (MD)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:A
Last Name:KONOPACKI
Suffix:
Gender:F
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:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-0217
Mailing Address - Country:US
Mailing Address - Phone:561-422-7577
Mailing Address - Fax:561-422-7615
Practice Address - Street 1:7305 N MILITARY TRL
Practice Address - Street 2:PRIMARY CARE (110)
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-7417
Practice Address - Country:US
Practice Address - Phone:561-422-7577
Practice Address - Fax:561-422-7615
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVADOOMedicare UPIN