Provider Demographics
NPI:1619961984
Name:KOPPENHOEFER, RON M (MD)
Entity Type:Individual
Prefix:DR
First Name:RON
Middle Name:M
Last Name:KOPPENHOEFER
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 1:8333 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-2227
Mailing Address - Country:US
Mailing Address - Phone:573-792-5600
Mailing Address - Fax:573-792-5604
Practice Address - Street 1:8333 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2227
Practice Address - Country:US
Practice Address - Phone:573-792-5600
Practice Address - Fax:573-792-5604
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3537270208100000X
KY20708208100000X
MI4301064876208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0333562Medicaid
OH9923102Medicare PIN
OH0333562Medicaid