Provider Demographics
NPI:1093763252
Name:KOPTIK, PETER C (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:KOPTIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 109 ATTN JULIE L
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2332 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1955
Practice Address - Country:US
Practice Address - Phone:616-391-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044839207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4791880Medicaid
MI0104103392OtherBCBS
MI4791834Medicaid
MI4791843Medicaid
MI1598712390OtherGROUP NPI
MI4791861Medicaid
MI4791870Medicaid
MIP00280464Medicare ID - Type UnspecifiedRAILROAD