Provider Demographics
NPI:1922086552
Name:DE BRUYN KOPS, JULIAN III (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIAN
Middle Name:
Last Name:DE BRUYN KOPS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 E 17TH
Mailing Address - Street 2:STE C
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-522-6106
Mailing Address - Fax:208-522-6142
Practice Address - Street 1:2065 E 17TH
Practice Address - Street 2:STE C
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-522-6106
Practice Address - Fax:208-522-6142
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMD3222207Q00000X
CAG25832207Q00000X
ORMD08869207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1109531Medicare ID - Type Unspecified
C36818Medicare UPIN