Healthcare Provider Details

I. General information

NPI: 1457960502
Provider Name (Legal Business Name): MISS TAMARA PAOLA GONZALEZ COPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 W RIVER DR NE
COMSTOCK PARK MI
49321-9602
US

IV. Provider business mailing address

4735 W RIVER DR NE
COMSTOCK PARK MI
49321-9602
US

V. Phone/Fax

Practice location:
  • Phone: 616-784-9400
  • Fax:
Mailing address:
  • Phone: 616-784-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351049611
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: