Provider Demographics
NPI:1780657841
Name:COPELAND, JACK ANDREW (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ANDREW
Last Name:COPELAND
Suffix:
Gender:M
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:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:MARFA
Mailing Address - State:TX
Mailing Address - Zip Code:79843-0387
Mailing Address - Country:US
Mailing Address - Phone:432-729-4608
Mailing Address - Fax:432-729-4653
Practice Address - Street 1:1010 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3456
Practice Address - Country:US
Practice Address - Phone:505-986-8468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-2132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D77853Medicare UPIN