Provider Demographics
NPI:1790755908
Name:COPELAND, VICTOR LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:LYNN
Last Name:COPELAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 ENCINITAS BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:760-436-1877
Mailing Address - Fax:760-632-7519
Practice Address - Street 1:1279 ENCINITAS BLVD
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024
Practice Address - Country:US
Practice Address - Phone:760-436-1877
Practice Address - Fax:760-632-7519
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5136TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD00513620Medicaid
CASD00513620Medicaid
OP5136Medicare ID - Type Unspecified