1982648101 NPI number — DR. GEORGE C KOPPUZHA M.D.

Table of content: DR. GEORGE C KOPPUZHA M.D. (NPI 1982648101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982648101 NPI number — DR. GEORGE C KOPPUZHA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOPPUZHA
Provider First Name:
GEORGE
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982648101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2091 TAMIAMI TRL
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33948-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-624-2787
Provider Business Mailing Address Fax Number:
855-211-3727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2091 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33948-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-625-9494
Provider Business Practice Location Address Fax Number:
941-743-8562
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME0074583 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 255240000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44529 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 279368 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: AK532 . This is a "MEDICARE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 100630100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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