Provider Demographics
NPI:1902242902
Name:KOEPPEN, ROBYN LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:LEIGH
Last Name:KOEPPEN
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4815 JOHNSTON OEHLER RD
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1065
Practice Address - Country:US
Practice Address - Phone:704-801-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00579207QS0010X, 207RS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC191641OtherRTL - RESIDENT TRAINING LICENSE NUMBER
NC1902242902Medicaid
SCNC2738Medicaid
NCAC5385578-R024OtherDEA
NCAC5385578-R024OtherDEA