Provider Demographics
NPI:1730129560
Name:KOPNICK, MITCHELL A (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:A
Last Name:KOPNICK
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 1:3200 E RACINE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2343
Mailing Address - Country:US
Mailing Address - Phone:608-371-8000
Mailing Address - Fax:608-371-8930
Practice Address - Street 1:3200 E RACINE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2343
Practice Address - Country:US
Practice Address - Phone:608-371-8000
Practice Address - Fax:608-371-8930
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39804-020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1730129560Medicaid
WI6272OtherDEAN HEALTH INSURANCE
WI32427400Medicaid
WIK40094506Medicare PIN
WI048874150Medicare PIN
WI010854340Medicare PIN
WI6272OtherDEAN HEALTH INSURANCE