Healthcare Provider Details

I. General information

NPI: 1437618469
Provider Name (Legal Business Name): JOLIE PORTANOVA COOPERMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/14/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 E CHEVY CHASE DR STE 355
GLENDALE CA
91206-4159
US

IV. Provider business mailing address

2100 POWELL ST STE 400
EMERYVILLE CA
94608-1872
US

V. Phone/Fax

Practice location:
  • Phone: 747-212-3441
  • Fax:
Mailing address:
  • Phone: 510-350-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number315538
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number315538
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA185999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: