Provider Demographics
NPI:1528013539
Name:KOPACZ, DAVID RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAYMOND
Last Name:KOPACZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:302 W HILL ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3562
Mailing Address - Country:US
Mailing Address - Phone:217-363-2891
Mailing Address - Fax:217-359-0322
Practice Address - Street 1:302 W HILL ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3562
Practice Address - Country:US
Practice Address - Phone:217-363-2891
Practice Address - Fax:217-359-0322
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG16719Medicare UPIN
IL210622Medicare ID - Type Unspecified