Provider Demographics
NPI:1215901038
Name:COPELAND, MARTIN R (OD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:R
Last Name:COPELAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 CORAL RIDGE AVE
Mailing Address - Street 2:STE 518
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2805
Mailing Address - Country:US
Mailing Address - Phone:917-532-9114
Mailing Address - Fax:
Practice Address - Street 1:101 SOUTH BERGEN PLACE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11120
Practice Address - Country:US
Practice Address - Phone:516-623-3600
Practice Address - Fax:516-623-9191
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006680152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02420322Medicaid
C380G1Medicare ID - Type Unspecified
U99676Medicare UPIN