Healthcare Provider Details

I. General information

NPI: 1326215724
Provider Name (Legal Business Name): KENNETH EDWARD KOPITZKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15100 RESCUE WAY USCG AIR STATION CLEARWATER CLINIC
CLEARWATER FL
33762
US

IV. Provider business mailing address

15100 RESCUE WAY USCG AIR STATION CLEARWATER CLINIC
CLEARWATER FL
33762
US

V. Phone/Fax

Practice location:
  • Phone: 727-535-1437
  • Fax: 727-535-4190
Mailing address:
  • Phone: 727-535-1437
  • Fax: 727-535-4190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: