Provider Demographics
NPI:1699847053
Name:KOPPEL, WALTER B (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:B
Last Name:KOPPEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8501 LASALLE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5914
Mailing Address - Country:US
Mailing Address - Phone:443-279-0330
Mailing Address - Fax:443-279-0334
Practice Address - Street 1:8501 LASALLE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5914
Practice Address - Country:US
Practice Address - Phone:443-279-0330
Practice Address - Fax:443-279-0334
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD15538207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5013Medicare ID - Type Unspecified
MDC49247Medicare UPIN