Provider Demographics
NPI:1093977985
Name:KOPITZKI, BRIAN A (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:KOPITZKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 215
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5400
Mailing Address - Country:US
Mailing Address - Phone:248-620-3376
Mailing Address - Fax:248-620-3376
Practice Address - Street 1:5701 BOW POINTE DR STE 215
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5400
Practice Address - Country:US
Practice Address - Phone:248-620-3376
Practice Address - Fax:248-620-3376
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015228207N00000X
IA4074207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM78790003Medicare PIN