Provider Demographics
NPI:1184619355
Name:KOPYNEC, BOHDAN WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:BOHDAN
Middle Name:WILLIAM
Last Name:KOPYNEC
Suffix:
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:PO BOX 843013
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3013
Mailing Address - Country:US
Mailing Address - Phone:910-652-2663
Mailing Address - Fax:910-652-3150
Practice Address - Street 1:112 E BALLARD ST
Practice Address - Street 2:
Practice Address - City:ELLERBE
Practice Address - State:NC
Practice Address - Zip Code:28338-9730
Practice Address - Country:US
Practice Address - Phone:910-652-2633
Practice Address - Fax:910-652-3150
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
6120496002OtherCIGNA PAL
7802441OtherAETNA
SCQ0142CMedicaid
NC1236EOtherBCBS
FH1000880OtherFIRST CAROLINA CARE
NC891236EMedicaid
SCQ0142CMedicaid
NC891236EMedicaid
080146653 RAILROADMedicare PIN