Provider Demographics
NPI:1043423825
Name:KOPLEN, MICHAEL ANDREW (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:KOPLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 14TH AVE APT 410
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062
Mailing Address - Country:US
Mailing Address - Phone:831-465-1160
Mailing Address - Fax:
Practice Address - Street 1:4895 CAPITOLA ROAD
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010
Practice Address - Country:US
Practice Address - Phone:831-475-6450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA18846111NI0013X
CA18846111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0188460Medicare ID - Type Unspecified