Healthcare Provider Details

I. General information

NPI: 1982964730
Provider Name (Legal Business Name): AMANDA LYNN KOPCZYK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA LYNN LEONHARD O.D.

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12876 W BLUEMOUND RD
ELM GROVE WI
53122-2605
US

IV. Provider business mailing address

16800 W CLEVELAND AVE
NEW BERLIN WI
53151-3533
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-0052
  • Fax: 262-923-7610
Mailing address:
  • Phone: 262-923-7298
  • Fax: 262-923-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number152W00000X
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: