Provider Demographics
NPI:1639128135
Name:KOPELOWITZ, WALLY (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLY
Middle Name:
Last Name:KOPELOWITZ
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 1:233 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205
Mailing Address - Country:US
Mailing Address - Phone:718-826-3911
Mailing Address - Fax:718-826-3860
Practice Address - Street 1:546 EASTERN PARKWAY
Practice Address - Street 2:EMPIRE CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225
Practice Address - Country:US
Practice Address - Phone:718-604-4800
Practice Address - Fax:718-604-4828
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1371321207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00460297Medicaid
B11529Medicare UPIN
25A282Medicare PIN