Healthcare Provider Details

I. General information

NPI: 1477644599
Provider Name (Legal Business Name): ANNA VERONICA KOPEC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. ANNA V SHAKALIS

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 KENNEDY BLVD
BAYONNE NJ
07002
US

IV. Provider business mailing address

730 KENNEDY BLVD
BAYONNE NJ
07002
US

V. Phone/Fax

Practice location:
  • Phone: 201-858-4300
  • Fax: 201-339-0708
Mailing address:
  • Phone: 201-858-4300
  • Fax: 201-339-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA03213900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: