=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154586378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY BURNETT KOPP MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2008
-----------------------------------------------------
Last Update Date | 07/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 CENTER DR, NIH BDG 10, 3N116
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20892-1268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-594-3403
-----------------------------------------------------
Fax | 301-402-0014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5510 LINCOLN ST
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20817-3354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-594-3403
-----------------------------------------------------
Fax | 301-402-0014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | D0038010
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------