Healthcare Provider Details

I. General information

NPI: 1265735013
Provider Name (Legal Business Name): PATRICIA MARY KOPKO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR MC8320
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

PO BOX 232410 MC8320
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-7669
  • Fax: 619-543-3730
Mailing address:
  • Phone: 619-543-5779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License NumberG75006
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZI0100X
TaxonomyImmunopathology Physician
License NumberG75006
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: