Provider Demographics
NPI:1346462181
Name:COPPOLA, JOHN CHRISTOPHER (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:400 LAKEBRIDGE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5157
Mailing Address - Country:US
Mailing Address - Phone:386-677-9044
Mailing Address - Fax:386-677-3083
Practice Address - Street 1:400 LAKEBRIDGE PLAZA DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5157
Practice Address - Country:US
Practice Address - Phone:386-677-9044
Practice Address - Fax:386-677-3083
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101016996207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDB709ZMedicare PIN
FLDB709YMedicare UPIN