Provider Demographics
NPI:1336186444
Name:H KENNETH KOPOLOW O.D & ASSOC P.C
Entity Type:Organization
Organization Name:H KENNETH KOPOLOW O.D & ASSOC P.C
Other - Org Name:DR. KENNETH KOPOLOW O.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARLAN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:KOPOLOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-733-6764
Mailing Address - Street 1:7361 W LAKE MEAD BLVD
Mailing Address - Street 2:STE 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:702-255-5797
Practice Address - Street 1:4300 MEADOWS LN
Practice Address - Street 2:STE 126
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-3004
Practice Address - Country:US
Practice Address - Phone:702-733-6764
Practice Address - Fax:702-614-6018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOPOLOW & GIRISGEN OD, PC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-31
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507862Medicaid
NVVWJBFKMedicare PIN
NVU55390Medicare UPIN