Basic Information
| Provider Information | |||||||||
| NPI: | 1700102928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOPKO | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5824 WIDEWATERS PKWY | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130573072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152513100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5719 WIDEWATERS PKWY | ||||||||
| Address2: | SYRACUSE ORTHOPEDIC SPECIALISTS | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152513100 | ||||||||
| FaxNumber: | 3154499923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 272408 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 272408 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 04704138 | 05 | NY | MEDICAID |