Provider Demographics
NPI:1124007125
Name:COPPOLA, GREGORY W (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:W
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:5215 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2419
Practice Address - Country:US
Practice Address - Phone:814-866-8610
Practice Address - Fax:814-866-8614
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010713L204D00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018041330009Medicaid
PA0018041330011Medicaid
PA0018041330009Medicaid