Provider Demographics
NPI:1679558258
Name:COPELAND, CARY LEWIS (DPM)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:LEWIS
Last Name:COPELAND
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 322
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-0322
Mailing Address - Country:US
Mailing Address - Phone:513-474-1906
Mailing Address - Fax:513-474-9272
Practice Address - Street 1:4260 GLENDALE MILFORD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-3704
Practice Address - Country:US
Practice Address - Phone:513-769-4408
Practice Address - Fax:513-769-4578
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-002638213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000250229OtherANTHEM
OH0908058Medicaid
OH480034608OtherRR MEDICARE
OHU01770Medicare UPIN
OH0672889Medicare PIN