Healthcare Provider Details

I. General information

NPI: 1235026287
Provider Name (Legal Business Name): IRENE VIVANCOS KOOPMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1301 COATES BLUFF DR APT 1332
SHREVEPORT LA
71104-2867
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0050
  • Fax:
Mailing address:
  • Phone: 512-484-9720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number347210
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: