Healthcare Provider Details

I. General information

NPI: 1396728663
Provider Name (Legal Business Name): MICHAEL JOHN KOP RDMS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SIPROCK NM
87420
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6020
  • Fax: 505-368-6431
Mailing address:
  • Phone: 505-368-6020
  • Fax: 505-368-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number26917
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: