Provider Demographics
NPI:1134101066
Name:KOPECKY, RICHARD T (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:KOPECKY
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 1:1304 BUCKLEY RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4302
Mailing Address - Country:US
Mailing Address - Phone:315-478-3311
Mailing Address - Fax:315-426-0796
Practice Address - Street 1:1304 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-4302
Practice Address - Country:US
Practice Address - Phone:315-478-3311
Practice Address - Fax:315-426-0796
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150197207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00907479Medicaid
NY00907479Medicaid
NY34576EMedicare ID - Type Unspecified