Provider Demographics
NPI:1043208325
Name:KOPELMAN, LARRY J (PT)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:J
Last Name:KOPELMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3908
Mailing Address - Country:US
Mailing Address - Phone:718-698-3055
Mailing Address - Fax:718-448-1875
Practice Address - Street 1:1428 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3908
Practice Address - Country:US
Practice Address - Phone:718-698-3055
Practice Address - Fax:718-448-1875
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0028321225100000X
SC5562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ06842Medicare ID - Type Unspecified