Provider Demographics
NPI:1669014213
Name:COPELAND, JASON EUSEPH (MBBS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:EUSEPH
Last Name:COPELAND
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 MAIN ST APT 1006
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-2715
Mailing Address - Country:US
Mailing Address - Phone:876-877-9100
Mailing Address - Fax:
Practice Address - Street 1:665 ELM AND CARLTON STREET ELM AND CARLTON STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-0001
Practice Address - Country:US
Practice Address - Phone:876-877-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6010250301208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty