Provider Demographics
NPI:1437194388
Name:KOPPERUD, TRACEY ANN (DO)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
Last Name:KOPPERUD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:A
Other - Last Name:ROEHRKASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3520 E LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6304
Mailing Address - Country:US
Mailing Address - Phone:208-888-0909
Mailing Address - Fax:208-888-5825
Practice Address - Street 1:3520 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6304
Practice Address - Country:US
Practice Address - Phone:208-888-0909
Practice Address - Fax:208-888-5825
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0690207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA21910OtherWELLMARK, CLIVE OFFICE
IA21910OtherWELLMARK, CLIVE OFFICE
IA0491969Medicaid
IA0491969Medicaid
IA21955OtherWELLMARK, ANKENY OFFICE