Provider Demographics
NPI:1306575691
Name:KOPECHEK, KYLE JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JACOB
Last Name:KOPECHEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 E MOUND ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1946
Mailing Address - Country:US
Mailing Address - Phone:440-465-9446
Mailing Address - Fax:
Practice Address - Street 1:915 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3153
Practice Address - Country:US
Practice Address - Phone:614-293-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.252220208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology