Provider Demographics
NPI:1194796235
Name:KOPECKO, KATHLEEN JOAN (OD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:JOAN
Last Name:KOPECKO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2581 NUT TREE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6915
Mailing Address - Country:US
Mailing Address - Phone:707-447-1332
Mailing Address - Fax:707-447-4894
Practice Address - Street 1:2581 NUT TREE RD
Practice Address - Street 2:SUITE C
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6915
Practice Address - Country:US
Practice Address - Phone:707-447-1332
Practice Address - Fax:707-447-4894
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0076550Medicaid
CA5417820001Medicare NSC
CASD0076553Medicare PIN
CASD0076550Medicaid
CASD0076552Medicare PIN
T10574Medicare UPIN