Provider Demographics
NPI:1063451516
Name:COPPOCK, MICHAEL (MC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COPPOCK
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-254-1240
Mailing Address - Fax:360-397-3128
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1913
Practice Address - Country:US
Practice Address - Phone:360-254-1240
Practice Address - Fax:360-397-3128
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8303869Medicaid
WA683869Medicare PIN
WA8303869Medicaid