Basic Information
| Provider Information | |||||||||
| NPI: | 1366855629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOPP | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11314 DAVENPORT CIR NE | ||||||||
| Address2: | UNIT D | ||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554494485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513036826 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10961 CLUB WEST PKWY | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554495866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635717550 | ||||||||
| FaxNumber: | 7632534142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2014 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3384 | MN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.