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General NPI Number Information
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NPI Number | 1780657841
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Entity Type | Individual
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Provider Name | JACK ANDREW COPELAND MD
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Gender | Male
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Dates
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Enumeration Date | 02/09/2006
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Last Update Date | 01/25/2010
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Provider Practice Location Address
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Address Line | 1010 SPRUCE ST
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City | ESPANOLA
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State | NM
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Zip | 87532-3456
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Country | US
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Telephone | 505-986-8468
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 387
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City | MARFA
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State | TX
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Zip | 79843-0387
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Country | US
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Telephone | 432-729-4608
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Fax | 432-729-4653
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 97-213
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License Number State | NM
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