Provider Demographics
NPI:1013962604
Name:KOPOLOW, HARLAN KENNETH (OD)
Entity Type:Individual
Prefix:
First Name:HARLAN
Middle Name:KENNETH
Last Name:KOPOLOW
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 1:7361 W LAKE MEAD BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1040
Mailing Address - Country:US
Mailing Address - Phone:702-733-6764
Mailing Address - Fax:702-255-5795
Practice Address - Street 1:8145 W SAHARA AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1994
Practice Address - Country:US
Practice Address - Phone:702-733-6764
Practice Address - Fax:702-255-5795
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002502050Medicaid
NVCY295AMedicare PIN
NVV102028Medicare PIN
NVV102759Medicare PIN
NVU55390Medicare UPIN
NV102131Medicare ID - Type Unspecified
NVVWJBFKMedicare PIN
NV002502050Medicaid
NVV102758Medicare PIN