Provider Demographics
NPI:1760623599
Name:COLLEEN COPELAN, M.D. INC
Entity Type:Organization
Organization Name:COLLEEN COPELAN, M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-659-1333
Mailing Address - Street 1:970 SOUTH PETIT AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004
Mailing Address - Country:US
Mailing Address - Phone:805-659-1333
Mailing Address - Fax:805-659-1408
Practice Address - Street 1:970 SOUTH PETIT AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004
Practice Address - Country:US
Practice Address - Phone:805-659-1333
Practice Address - Fax:805-659-1408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLEEN COPELAN MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-06
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG220182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F47150Medicare UPIN