Provider Demographics
NPI:1336463363
Name:STANLEY M KOPELOW M D INC
Entity Type:Organization
Organization Name:STANLEY M KOPELOW M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:KOLELOW
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:818-990-3623
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE # 750
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4325
Mailing Address - Country:US
Mailing Address - Phone:818-990-3623
Mailing Address - Fax:818-788-1056
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE # 750
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4325
Practice Address - Country:US
Practice Address - Phone:818-990-3623
Practice Address - Fax:818-788-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-19
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG14728207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39322Medicare UPIN
CAA39322Medicare PIN