Healthcare Provider Details

I. General information

NPI: 1275792368
Provider Name (Legal Business Name): JOANNA KOPACZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24411 HEALTH CENTER DR STE 560
LAGUNA HILLS CA
92653-3687
US

IV. Provider business mailing address

PO BOX 29491
SAINT LOUIS MO
63126-7491
US

V. Phone/Fax

Practice location:
  • Phone: 949-218-7251
  • Fax:
Mailing address:
  • Phone: 949-218-7251
  • Fax: 949-209-2669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number262583
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA128174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: