Provider Demographics
NPI:1235026287
Name:VIVANCOS KOOPMAN, IRENE (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:VIVANCOS KOOPMAN
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 1:1301 COATES BLUFF DR APT 1332
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2867
Mailing Address - Country:US
Mailing Address - Phone:512-484-9720
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA347210390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program