Provider Demographics
NPI:1730152786
Name:COPELAND, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:COPELAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W. ARBOR DR.
Mailing Address - Street 2:MC 8892
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-543-7777
Mailing Address - Fax:619-543-2652
Practice Address - Street 1:200 W. ARBOR DR.
Practice Address - Street 2:MC 8892
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-543-7777
Practice Address - Fax:619-543-2652
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9927208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ330002923OtherRR MEDICARE
AZ220997Medicaid
AZZ33WCGCR03Medicare PIN
AZ220997Medicaid