Provider Demographics
NPI:1346211158
Name:KOPRIVICA, JASMINA (OD)
Entity Type:Individual
Prefix:DR
First Name:JASMINA
Middle Name:
Last Name:KOPRIVICA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N INDIAN HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4607
Mailing Address - Country:US
Mailing Address - Phone:909-621-3952
Mailing Address - Fax:909-626-5260
Practice Address - Street 1:120 N INDIAN HILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4607
Practice Address - Country:US
Practice Address - Phone:909-621-3952
Practice Address - Fax:909-626-5260
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10353T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103530Medicaid
CA5631920001Medicare NSC
CASD0103530Medicaid