Healthcare Provider Details

I. General information

NPI: 1346205846
Provider Name (Legal Business Name): STEVEN KOPITZKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 VOLUNTEER PKWY
BRISTOL TN
37620-4628
US

IV. Provider business mailing address

999 EXECUTIVE PARK BLVD SUITE 201
KINGSPORT TN
37660-4632
US

V. Phone/Fax

Practice location:
  • Phone: 423-990-1400
  • Fax: 423-990-1411
Mailing address:
  • Phone: 423-224-3250
  • Fax: 423-224-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15960
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: