Provider Demographics
NPI:1407086960
Name:KOEPPE, MICHAEL ADAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ADAM
Last Name:KOEPPE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3232 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-280-3000
Mailing Address - Fax:701-280-1304
Practice Address - Street 1:3232 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-280-3000
Practice Address - Fax:701-280-1304
Is Sole Proprietor?:No
Enumeration Date:2009-07-19
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN714659OtherMEDICARE PTAN