Provider Demographics
NPI:1336388586
Name:KOPP, FABIOLLA SIQUEIRA (MD)
Entity Type:Individual
Prefix:
First Name:FABIOLLA
Middle Name:SIQUEIRA
Last Name:KOPP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1858
Mailing Address - Country:US
Mailing Address - Phone:773-257-6114
Mailing Address - Fax:
Practice Address - Street 1:1401 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1858
Practice Address - Country:US
Practice Address - Phone:773-257-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5683208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation