Healthcare Provider Details

I. General information

NPI: 1437264645
Provider Name (Legal Business Name): MARK J KOPEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11150 HIGHLAND RD
HARTLAND MI
48353-2702
US

IV. Provider business mailing address

11150 HIGHLAND RD
HARTLAND MI
48353-2702
US

V. Phone/Fax

Practice location:
  • Phone: 810-632-6380
  • Fax: 810-632-6601
Mailing address:
  • Phone: 810-632-6380
  • Fax: 810-632-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMK008618
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: