MEDICARE: DR. AMANDA LYNN KOPCZYK O.D.

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
1	152W00000X	Optometrist	152W00000X	WI

General Provider Information

NPI Number	:	1982964730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA LYNN KOPCZYK O.D.

Provider Business Mailing Address
First Line	:	16800 W CLEVELAND AVE
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-3533
Country	:	US
Telephone Number	:	262-923-7298
Fax Number	:	262-923-7299

Provider Business Practice Location Address
First Line	:	12876 W BLUEMOUND RD
Second Line	:
City	:	ELM GROVE
State	:	WI
Zip	:	53122-2605
Country	:	US
Telephone Number	:	262-432-0052
Fax Number	:	262-923-7610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2012
Last Update Date	:	08/13/2014

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