Basic Information
| Provider Information | |||||||||
| NPI: | 1699077909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOPP MULBERG | ||||||||
| FirstName: | FERN | ||||||||
| MiddleName: | ELYSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758952 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212758952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049685700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 MANTUA PIKE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080963233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568122220 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2010 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS008386L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25MB05948700 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | H0076671 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.