Provider Demographics
NPI:1629577366
Name:KOPOLOW & GIRISGEN PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KOPOLOW & GIRISGEN PROFESSIONAL CORPORATION
Other - Org Name:KOPOLOW & GIRISGEN OD PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:T
Authorized Official - Last Name:GIRISGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-275-5229
Mailing Address - Street 1:4045 SPENCER ST STE A59
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-9311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5465 MEADOWOOD MALL CIR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6710
Practice Address - Country:US
Practice Address - Phone:702-341-7254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1518904622Medicaid