Healthcare Provider Details

I. General information

NPI: 1245203553
Provider Name (Legal Business Name): MYRON KOPIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 W UNIVERSITY DR SUITE 415
ROCHESTER MI
48307-1871
US

IV. Provider business mailing address

1135 W UNIVERSITY DR SUITE 415
ROCHESTER MI
48307-1871
US

V. Phone/Fax

Practice location:
  • Phone: 248-656-1222
  • Fax: 248-650-4575
Mailing address:
  • Phone: 248-656-1222
  • Fax: 248-650-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMK036050
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: