Provider Demographics
NPI:1184696171
Name:KOPP, JOHN D (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:KOPP
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 1:6 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3791
Mailing Address - Country:US
Mailing Address - Phone:518-482-9111
Mailing Address - Fax:518-482-6142
Practice Address - Street 1:6 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3791
Practice Address - Country:US
Practice Address - Phone:518-482-9111
Practice Address - Fax:518-482-6142
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184904174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01264635Medicaid
NY5093468OtherAETNA
NY03G682OtherEMPIRE BLUE CROSS
NY10001093OtherCDPHP
NY04147OtherMVP
NY0600071OtherGHI
NY000405427004OtherBLUE SHIELD
NY040426005185OtherFIDELIS
NY11207OtherWELLCARE
NY10001093OtherCDPHP
NY0600071OtherGHI