Provider Demographics
NPI:1790875714
Name:KOPPARI, WILLIAM JEFFREY (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JEFFREY
Last Name:KOPPARI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5896 TARGEE TRL
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8301
Mailing Address - Country:US
Mailing Address - Phone:815-623-3468
Mailing Address - Fax:
Practice Address - Street 1:5290 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9222
Practice Address - Country:US
Practice Address - Phone:815-623-3379
Practice Address - Fax:815-623-3380
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10121334OtherBCBS OF IL PROVIDER NUMBE
IL10121334OtherBCBS OF IL PROVIDER NUMBE