Healthcare Provider Details

I. General information

NPI: 1548436132
Provider Name (Legal Business Name): MONICA CAROLINA KOPLAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET
JACKSON MS
39216
US

IV. Provider business mailing address

2500 NORTH STATE STREET
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-2538
  • Fax: 601-815-1854
Mailing address:
  • Phone: 601-984-2538
  • Fax: 601-815-1854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number57.009693
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number21084
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: