=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518934058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRIS H KOPELOFF M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2006
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 E RIDGEWOOD AVE SUITE 107
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-3957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-689-2103
-----------------------------------------------------
Fax | 201-689-2108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 E RIDGEWOOD AVE SUITE 107
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-3957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-689-2103
-----------------------------------------------------
Fax | 201-689-2108
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MA59835
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------