Provider Demographics
NPI:1104485242
Name:KOPP, PAUL C
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:C
Last Name:KOPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 PORTOFINO PT APT M2
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-1241
Mailing Address - Country:US
Mailing Address - Phone:954-821-8404
Mailing Address - Fax:
Practice Address - Street 1:3201 PORTOFINO PT APT M2
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-1241
Practice Address - Country:US
Practice Address - Phone:954-821-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234320310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL753448Medicaid