Provider Demographics
NPI:1609955491
Name:KOPPIKAR, MAHESH M (MD)
Entity Type:Individual
Prefix:
First Name:MAHESH
Middle Name:M
Last Name:KOPPIKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 CUP LEAF HOLLY CT
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-1218
Mailing Address - Country:US
Mailing Address - Phone:703-406-9794
Mailing Address - Fax:
Practice Address - Street 1:1035 CUP LEAF HOLLY CT
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:VA
Practice Address - Zip Code:22066-1218
Practice Address - Country:US
Practice Address - Phone:703-406-9794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV135402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64033962Medicaid
WV0123643000Medicaid
WVKO4169821Medicare ID - Type Unspecified
WVD49378Medicare UPIN