Provider Demographics
NPI:1912948258
Name:KOPACZ, MACIEJ J (MD)
Entity Type:Individual
Prefix:
First Name:MACIEJ
Middle Name:J
Last Name:KOPACZ
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 1:8713 N DEL MAR AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-6949
Mailing Address - Country:US
Mailing Address - Phone:559-436-4704
Mailing Address - Fax:
Practice Address - Street 1:15 E. AUBUBON DRIVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-433-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30344207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A303440Medicaid
CABP655XMedicare PIN
CABP655YMedicare PIN
CA00A303440Medicaid
CAP00789891Medicare PIN
CA00A303441Medicare ID - Type Unspecified