Provider Demographics
NPI:1336385574
Name:ROBERT KOPPANY
Entity Type:Organization
Organization Name:ROBERT KOPPANY
Other - Org Name:ADVANCED OPTOMETRIC EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPPANY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-243-4559
Mailing Address - Street 1:15908 BEAR VALLEY RD # A
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-9547
Mailing Address - Country:US
Mailing Address - Phone:760-243-4559
Mailing Address - Fax:760-243-2052
Practice Address - Street 1:15908 BEAR VALLEY RD # A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-9547
Practice Address - Country:US
Practice Address - Phone:760-243-4559
Practice Address - Fax:760-243-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8523TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0085230Medicaid
CAT70272 CAMedicare UPIN