Healthcare Provider Details

I. General information

NPI: 1063451516
Provider Name (Legal Business Name): MICHAEL COPPOCK MC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-1240
  • Fax: 360-397-3128
Mailing address:
  • Phone: 360-254-1240
  • Fax: 360-397-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00025260
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: