Provider Demographics
NPI:1104323997
Name:KOPENITZ, JASON (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KOPENITZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 117661
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7661
Mailing Address - Country:US
Mailing Address - Phone:704-749-5800
Mailing Address - Fax:
Practice Address - Street 1:3735 GLENLAKE DR STE 250
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-6866
Practice Address - Country:US
Practice Address - Phone:704-749-5800
Practice Address - Fax:704-626-3237
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-00657207L00000X
SC91310207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology