Healthcare Provider Details

I. General information

NPI: 1609805514
Provider Name (Legal Business Name): JUDITH ANN KOPERSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE 530
LA JOLLA CA
92037-1224
US

IV. Provider business mailing address

3613 VISTA WAY
OCEANSIDE CA
92056-4522
US

V. Phone/Fax

Practice location:
  • Phone: 858-558-0677
  • Fax: 858-558-3077
Mailing address:
  • Phone: 760-758-5340
  • Fax: 760-758-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG51030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: