Provider Demographics
NPI:1134283138
Name:COQUELET AND PUNGER FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:COQUELET AND PUNGER FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DINOCOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-466-8884
Mailing Address - Street 1:4640 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5057
Mailing Address - Country:US
Mailing Address - Phone:772-466-8832
Mailing Address - Fax:
Practice Address - Street 1:4640 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5057
Practice Address - Country:US
Practice Address - Phone:772-466-8832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68275207Q00000X
FLOS6690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269585500Medicaid
FL74659OtherBCBS OF FL
FLDD5441OtherRAILROAD MEDICARE
FL23089OtherSOUTHCARE-COVENTRY HEALTH
FL=========OtherTRICARE FOR LIFE
FL=========OtherBROADSPIRE
FL23089OtherSOUTHCARE-COVENTRY HEALTH
FL=========OtherUSAA LIFE INSURANCE COMPA
FL=========OtherUSIS
FLDD5441OtherRAILROAD MEDICARE
FL=========OtherWEBTPA
FL=========OtherUNICARE
FL=========OtherTRICARE SOUTH
FL=========OtherPEARCE ADMINISTRATION
FL=========OtherBEECH STREET
FL=========OtherHUMANA
FL269585500Medicaid
FL=========OtherWEBTPA
FL=========OtherUNICARE
FL=========OtherBEECH STREET