Provider Demographics
NPI:1619958501
Name:COPELAND, LEE ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:ROY
Last Name:COPELAND
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:PO BOX 28946
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729
Mailing Address - Country:US
Mailing Address - Phone:559-228-4311
Mailing Address - Fax:559-224-9817
Practice Address - Street 1:7145 N CHESTNUT AVE
Practice Address - Street 2:STE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0359
Practice Address - Country:US
Practice Address - Phone:559-326-2182
Practice Address - Fax:559-326-2170
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32186207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G321860OtherBLUE CROSS/BLUE SHIELD
CA00G321860Medicaid
CA110115369OtherRAILROAD MEDICARE
CA77040368493612B008OtherCHAMPUS
CA00G321860Medicare ID - Type Unspecified
CA00G321860Medicaid