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NPI Code Detail

MEDICARE: JACK ANDREW COPELAND MD

MEDICARE: JACK ANDREW COPELAND MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician97-213NM

General Provider Information

NPI Number : 1780657841
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK ANDREW COPELAND MD
Provider Business Mailing Address
First Line : PO BOX 387
Second Line :
City : MARFA
State : TX
Zip : 79843-0387
Country : US
Telephone Number : 432-729-4608
Fax Number : 432-729-4653
Provider Business Practice Location Address
First Line : 1010 SPRUCE ST
Second Line :
City : ESPANOLA
State : NM
Zip : 87532-3456
Country : US
Telephone Number : 505-986-8468
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/09/2006
Last Update Date : 01/25/2010

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