Healthcare Provider Details

I. General information

NPI: 1598192890
Provider Name (Legal Business Name): JOHN S. KOPPMAN MD PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 904-826-3469
  • Fax:
Mailing address:
  • Phone: 904-826-3469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME93820
License Number StateFL

VIII. Authorized Official

Name: JOHN S KOPPMAN
Title or Position: OWNER
Credential: MD
Phone: 904-826-3469