MEDICARE: MS. SVETLANA KOPACZ MSED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	569696111	NY
2	174400000X	Specialist	569695111	NY

General Provider Information

NPI Number	:	1407119829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SVETLANA KOPACZ MSED

Provider Business Mailing Address
First Line	:	2990 BRIGHTON 12 STREET, APT # 5E
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235
Country	:	US
Telephone Number	:	917-702-0636
Fax Number	:

Provider Business Practice Location Address
First Line	:	2990 BRIGHTON 12 STREET
Second Line	:	APT 5E
City	:	BROOKLYN
State	:	NY
Zip	:	11235
Country	:	US
Telephone Number	:	917-702-0636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	06/20/2012

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