Provider Demographics
NPI:1851741425
Name:KOOPMAN, HOLLY RAEANN (OD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:RAEANN
Last Name:KOOPMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1524
Mailing Address - Country:US
Mailing Address - Phone:502-813-8928
Mailing Address - Fax:502-456-9121
Practice Address - Street 1:6812 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3914
Practice Address - Country:US
Practice Address - Phone:502-933-7986
Practice Address - Fax:502-933-2652
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004061A152W00000X
KY2017DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18004061AOtherINDIANA LICENSE NUMBER
IN221390002OtherINDIANA MEDICARE
KY7100492340Medicaid
KYK249890OtherKENTUCKY MEDICARE
KY2017DTOtherKENTUCKY LIENSE
KY2017DTOtherKENTUCKY LICENSE NUMBER
INPENDINGMedicaid