Provider Demographics
NPI:1114948668
Name:COPELAND, KIMBERLY H (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:H
Last Name:COPELAND
Suffix:
Gender:F
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:PO BOX 2077
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2077
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:2121 NE 139TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2316
Practice Address - Country:US
Practice Address - Phone:360-487-1777
Practice Address - Fax:360-487-1779
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21409207PP0204X
WAMD00044472208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00044472OtherWA STATE LICENSE
WAPENDINGMedicaid
F71022Medicare UPIN
OR110902Medicare ID - Type Unspecified
WAPENDINGMedicaid