1821194747 NPI number — DR. MARTHA L COPPAGE MD

Table of content: DR. MARTHA L COPPAGE MD (NPI 1821194747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821194747 NPI number — DR. MARTHA L COPPAGE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COPPAGE
Provider First Name:
MARTHA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COPPAGE-HOOVER
Provider Other First Name:
MARTHA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821194747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 YOUNGSVILLE HWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-5173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-330-0031
Provider Business Mailing Address Fax Number:
337-330-0059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2309 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
NEW IBERIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70560-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-367-2001
Provider Business Practice Location Address Fax Number:
337-365-3050
Provider Enumeration Date:
09/16/2006

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: 207V00000X , with the licence number:  MD.022088 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1664847 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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