Healthcare Provider Details

I. General information

NPI: 1952364713
Provider Name (Legal Business Name): JOHN S KOPPMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HEALTH PARK BLVD SUITE 103
ST AUGUSTINE FL
32086-5796
US

IV. Provider business mailing address

201 HEALTH PARK BLVD SUITE 103
ST AUGUSTINE FL
32086-5796
US

V. Phone/Fax

Practice location:
  • Phone: 904-827-0093
  • Fax:
Mailing address:
  • Phone: 904-827-0093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0093820
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: