Basic Information
Provider Information | |||||||||
NPI: | 1326079799 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COPELAND | ||||||||
FirstName: | RANDOLPH | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 516 E. NIZHONI BLVD. | ||||||||
Address2: | BOX 1337 | ||||||||
City: | GALLUP | ||||||||
State: | NM | ||||||||
PostalCode: | 873011337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5057221000 | ||||||||
FaxNumber: | 5057221256 | ||||||||
Practice Location | |||||||||
Address1: | 516 E. NIZHONI BLVD. | ||||||||
Address2: | BOX 1337 | ||||||||
City: | GALLUP | ||||||||
State: | NM | ||||||||
PostalCode: | 873011337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5057221000 | ||||||||
FaxNumber: | 5057221256 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 02/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | 025131 | GA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207X00000X | MD.013119 | LA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 000E5728 | 05 | NM |   | MEDICAID | 580218 | 05 | AZ |   | MEDICAID |