Provider Demographics
NPI:1790531473
Name:KOPICKO, KERRIE (DO)
Entity type:Individual
Prefix:
First Name:KERRIE
Middle Name:
Last Name:KOPICKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29120 GLENARDEN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27483 DEQUINDRE RD STE 301
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-5715
Practice Address - Country:US
Practice Address - Phone:248-546-2600
Practice Address - Fax:248-546-2604
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151016938390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program