Provider Demographics
NPI:1871656066
Name:KOPAN, THOMAS CHRIS (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CHRIS
Last Name:KOPAN
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 1:1501 WEST KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-1605
Mailing Address - Country:US
Mailing Address - Phone:956-354-3915
Mailing Address - Fax:956-354-3916
Practice Address - Street 1:1501 WEST KELLY AVE
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-1605
Practice Address - Country:US
Practice Address - Phone:956-354-3915
Practice Address - Fax:956-354-3916
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6272T152W00000X
TX7020T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0062721Medicaid
TX271004OtherMEDICARE PTAN
CASD0062721Medicaid
T70102Medicare UPIN