Provider Demographics
NPI:1982660726
Name:KOPPENBRINK, WALTER EDWIN III (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:EDWIN
Last Name:KOPPENBRINK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4350 E CAMELBACK RD
Mailing Address - Street 2:SUITE F100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2701
Mailing Address - Country:US
Mailing Address - Phone:602-955-8700
Mailing Address - Fax:602-553-8142
Practice Address - Street 1:4350 E CAMELBACK RD
Practice Address - Street 2:SUITE F100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2701
Practice Address - Country:US
Practice Address - Phone:602-955-8700
Practice Address - Fax:602-553-8142
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11324207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D44130Medicare UPIN
Z102723Medicare PIN
Z124979Medicare PIN
Z124980Medicare PIN