Provider Demographics
NPI:1891061412
Name:MARTIN, KOPRIVA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KOPRIVA
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KOPRIVA
Other - Middle Name:MARIE
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-718-6479
Mailing Address - Fax:336-718-9622
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-718-6479
Practice Address - Fax:336-718-9622
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00658207R00000X, 208M00000X
SC40136207R00000X
WAMD61025441208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC401363Medicaid
SC401363Medicaid