1851355044 NPI number — MR. PETER G COPPOLA P. T.

Table of content: MR. PETER G COPPOLA P. T. (NPI 1851355044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851355044 NPI number — MR. PETER G COPPOLA P. T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COPPOLA
Provider First Name:
PETER
Provider Middle Name:
G
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P. T.
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:
1851355044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3024 NE 67TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97213-5204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-893-8987
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6504 NE SISKIYOU ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-4572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-893-8987
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2006

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: 225100000X , with the licence number:  60861 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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