Provider Demographics
NPI:1396057956
Name:COPELAND, GINA C (OD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:C
Last Name:COPELAND
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 1:60 LANDOVER PKWY
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-7513
Mailing Address - Country:US
Mailing Address - Phone:847-550-6558
Mailing Address - Fax:
Practice Address - Street 1:60 LANDOVER PKWY
Practice Address - Street 2:
Practice Address - City:HAWTHORN WOODS
Practice Address - State:IL
Practice Address - Zip Code:60047-7513
Practice Address - Country:US
Practice Address - Phone:847-550-6558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010379Medicaid