Provider Demographics
NPI:1801896394
Name:KOEPNICK, LANCE MITCHELL (OD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:MITCHELL
Last Name:KOEPNICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11654 N KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1005
Mailing Address - Country:US
Mailing Address - Phone:305-271-1364
Mailing Address - Fax:305-596-4237
Practice Address - Street 1:11654 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1005
Practice Address - Country:US
Practice Address - Phone:305-271-1364
Practice Address - Fax:305-596-4237
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2066152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20582ZMedicare ID - Type Unspecified