Basic Information
| Provider Information | |||||||||
| NPI: | 1164461802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPOLOFF | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3811 E BELL RD | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804200749 | ||||||||
| FaxNumber: | 4804200732 | ||||||||
| Practice Location | |||||||||
| Address1: | 3811 E BELL RD | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804200749 | ||||||||
| FaxNumber: | 4804200732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 0355 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 129181 | 05 | AZ | MEDICAID | 2Z1833 | 01 | AZ | HEALTH NET AZ | OTHER | 6202669 | 01 | AZ | GHI | OTHER | AZ0195160 | 01 | AZ | BCBS | OTHER | 113710768 | 01 | AZ | TRICARE | OTHER | 11178489 | 01 | AZ | CAQH | OTHER | 6624646 | 01 | AZ | CIGNA | OTHER | 4496171 | 01 | AZ | AETNA | OTHER |