Provider Demographics
NPI:1366855629
Name:KOPP, CHARLES JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:KOPP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:11314 DAVENPORT CIR NE
Mailing Address - Street 2:UNIT D
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4485
Mailing Address - Country:US
Mailing Address - Phone:651-303-6826
Mailing Address - Fax:
Practice Address - Street 1:10961 CLUB WEST PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5866
Practice Address - Country:US
Practice Address - Phone:763-571-7550
Practice Address - Fax:763-253-4142
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3384152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist