Provider Demographics
NPI:1003125733
Name:WALTER B KOPPEL PC
Entity type:Organization
Organization Name:WALTER B KOPPEL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:B
Authorized Official - Last Name:KOPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-279-0330
Mailing Address - Street 1:8501 LASALLE RD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5914
Mailing Address - Country:US
Mailing Address - Phone:443-279-0330
Mailing Address - Fax:443-279-0334
Practice Address - Street 1:8501 LASALLE RD
Practice Address - Street 2:SUITE #202
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5914
Practice Address - Country:US
Practice Address - Phone:443-279-0330
Practice Address - Fax:443-279-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD15538207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC49247Medicare UPIN