Provider Demographics
NPI:1427067339
Name:KEIBEL, MARTIN MARK
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:MARK
Last Name:KEIBEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 MIDDLE TPKE E
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3730
Mailing Address - Country:US
Mailing Address - Phone:860-646-4334
Mailing Address - Fax:860-646-7020
Practice Address - Street 1:574 MIDDLE TPKE E
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3730
Practice Address - Country:US
Practice Address - Phone:860-646-4334
Practice Address - Fax:860-646-7020
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP00064445OtherMEDICARE RR
CTB38823Medicare UPIN