Provider Demographics
NPI:1245436013
Name:KOPULOS, LUKE (MD)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:KOPULOS
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 1:804 SERVICE ROAD
Mailing Address - Street 2:ROOM D100
Mailing Address - City:EAST LALNSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7062
Mailing Address - Country:US
Mailing Address - Phone:517-355-5053
Mailing Address - Fax:517-432-4394
Practice Address - Street 1:804 SERVICE ROAD
Practice Address - Street 2:ROOM D100
Practice Address - City:EAST LALNSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7062
Practice Address - Country:US
Practice Address - Phone:517-355-5053
Practice Address - Fax:517-432-4394
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125052708390200000X
MI43011025492085R0202X
IL036-1369312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245436013Medicaid