Provider Demographics
NPI:1790043800
Name:KOPA, JUSTIN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JAMES
Last Name:KOPA
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 1:853 LONGWOOD AVE STE 201
Mailing Address - Street 2:COMMUNITY PEDIATRIC PROGRAMS
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-4036
Mailing Address - Country:US
Mailing Address - Phone:718-588-4460
Mailing Address - Fax:
Practice Address - Street 1:853 LONGWOOD AVE STE 201
Practice Address - Street 2:COMMUNITY PEDIATRIC PROGRAMS
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-4036
Practice Address - Country:US
Practice Address - Phone:718-588-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY279148-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics