Provider Demographics
NPI:1780612945
Name:COPPERS, MICHAEL GUST (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GUST
Last Name:COPPERS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15810 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3711
Mailing Address - Country:US
Mailing Address - Phone:440-529-1800
Mailing Address - Fax:216-529-3201
Practice Address - Street 1:15810 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3711
Practice Address - Country:US
Practice Address - Phone:216-529-1800
Practice Address - Fax:216-529-3201
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001751213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0368909Medicaid
OHCO0429273Medicare ID - Type Unspecified
OHP00466998Medicare PIN
OH0368909Medicaid
OHT90433Medicare UPIN
OH0429277Medicare PIN