Provider Demographics
NPI:1164512927
Name:KOPPERMAN, MORDECAI (MD)
Entity Type:Individual
Prefix:
First Name:MORDECAI
Middle Name:
Last Name:KOPPERMAN
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 1:119 W IRON AVE FL 5
Mailing Address - Street 2:PO BOX 2327
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-2600
Mailing Address - Country:US
Mailing Address - Phone:785-827-9526
Mailing Address - Fax:785-827-2854
Practice Address - Street 1:119 W IRON AVE FL 5
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-2600
Practice Address - Country:US
Practice Address - Phone:785-827-9526
Practice Address - Fax:785-827-2854
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-163182085B0100X, 2085N0700X, 2085N0904X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100088880AMedicaid
KS100088880AMedicaid