Provider Demographics
NPI:1184675431
Name:KOPP, TERRY W (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:W
Last Name:KOPP
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 1:5200 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11725 STINSON AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9542
Practice Address - Country:US
Practice Address - Phone:651-257-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE40275Medicare UPIN