Provider Demographics
NPI:1396728663
Name:KOP, MICHAEL JOHN (RDMS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:KOP
Suffix:
Gender:M
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420
Mailing Address - Country:US
Mailing Address - Phone:505-368-6020
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6020
Practice Address - Fax:505-368-6431
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
269172471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography