Provider Demographics
NPI:1679578769
Name:COPELAND, OLIVER PRESTON (MD)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:PRESTON
Last Name:COPELAND
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:PO BOX 421209
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77242-1209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 HWY 59 BYPASS
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488
Practice Address - Country:US
Practice Address - Phone:713-481-3533
Practice Address - Fax:713-432-0221
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD65622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10019839OtherAMERIGROUP
TX135670106Medicaid
TX81R652OtherBCBS
TX300079682OtherTRAVELERS MEDICARE
TX82W999OtherBCBS-STMC
TX8DE523OtherBC/BS #
TX135670102Medicaid
TX300015119OtherRAILROAD MEDICARE
TXMDD6562TXOtherWORKER'S COMP
TX135670109Medicaid
TX300015119OtherRAILROAD MEDICARE
TX300079682OtherTRAVELERS MEDICARE
TX81R652Medicare PIN
TXTXB154052Medicare PIN