Provider Demographics
NPI:1669450656
Name:KOPITNIK, THOMAS A JR (MD FACS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:KOPITNIK
Suffix:JR
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4348
Mailing Address - Country:US
Mailing Address - Phone:307-266-4000
Mailing Address - Fax:307-266-4545
Practice Address - Street 1:6600 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4348
Practice Address - Country:US
Practice Address - Phone:307-266-4000
Practice Address - Fax:307-266-4545
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6959A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119714200Medicaid
WYE64904Medicare UPIN
WY119714200Medicaid