Provider Demographics
NPI:1326055906
Name:COPPOLELLI, BERNARD G (DPM)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:G
Last Name:COPPOLELLI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 SANDY BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-5864
Mailing Address - Country:US
Mailing Address - Phone:401-828-1811
Mailing Address - Fax:401-823-0065
Practice Address - Street 1:134 SANDY BOTTOM RD
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-5864
Practice Address - Country:US
Practice Address - Phone:401-828-1811
Practice Address - Fax:401-823-0065
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM252213E00000X
MA1937213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9007049Medicaid
RI9007049Medicaid
RI007056778Medicare PIN