Healthcare Provider Details

I. General information

NPI: 1912811738
Provider Name (Legal Business Name): MR. RONALD JAY KOPPERDAHL I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 BROADWAY N STE 2
FARGO ND
58102-1439
US

IV. Provider business mailing address

PO BOX 126
HORACE ND
58047-0126
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-3231
  • Fax:
Mailing address:
  • Phone: 701-235-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberKOP-60-6932
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: