Healthcare Provider Details

I. General information

NPI: 1851369151
Provider Name (Legal Business Name): LESLIE A KOPIETZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PHALEN BLVD MAIL STOP 41102E
ST PAUL MN
55101-5302
US

IV. Provider business mailing address

8100 34TH AVE S 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-7500
  • Fax: 651-254-7557
Mailing address:
  • Phone: 952-883-5790
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number27614
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: