Provider Demographics
NPI:1003964255
Name:KOPPENOL, CAROLYN S (MD)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:S
Last Name:KOPPENOL
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 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-354-2197
Mailing Address - Fax:989-356-6524
Practice Address - Street 1:15774 STATE STREET
Practice Address - Street 2:
Practice Address - City:HILLMAN
Practice Address - State:MI
Practice Address - Zip Code:49746-0427
Practice Address - Country:US
Practice Address - Phone:989-742-4583
Practice Address - Fax:989-742-2183
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010460302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICK046030OtherSTATE LICENSE NUMBER
MI5104939Medicaid
MI5104939Medicaid
B43576Medicare UPIN