Healthcare Provider Details

I. General information

NPI: 1962648410
Provider Name (Legal Business Name): BRADLEY BENTON COPPLE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 W CENTER RD
OMAHA NE
68106-2700
US

IV. Provider business mailing address

7100 W CENTER RD
OMAHA NE
68106-2700
US

V. Phone/Fax

Practice location:
  • Phone: 402-506-9127
  • Fax: 402-261-0243
Mailing address:
  • Phone: 402-506-9127
  • Fax: 402-261-0243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number874
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number315
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: