Provider Demographics
NPI:1386613354
Name:KONOPASKE, GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:KONOPASKE
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 1:189 STORRS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1683
Mailing Address - Country:US
Mailing Address - Phone:860-456-1311
Mailing Address - Fax:
Practice Address - Street 1:UCONN HEALTH
Practice Address - Street 2:DEPT. OF PSYCHIATRY, 263 FARMINGTON AVE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-1105
Practice Address - Fax:860-679-1489
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT401122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013004610001Medicaid
PA076198Medicare ID - Type Unspecified
PA1013004610001Medicaid