Healthcare Provider Details

I. General information

NPI: 1245282417
Provider Name (Legal Business Name): ELIZABETH A KOPIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MLK JR BLVD SUITE 300
WORCESTER MA
01608-1209
US

IV. Provider business mailing address

100 MLK JR BLVD SUITE 300
WORCESTER MA
01608-1209
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-4861
  • Fax: 508-752-1392
Mailing address:
  • Phone: 508-755-4861
  • Fax: 508-752-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number56794
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: