Provider Demographics
NPI:1437140944
Name:COPPOCK, LAWRENCE HAYES (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:HAYES
Last Name:COPPOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-1754
Mailing Address - Country:US
Mailing Address - Phone:856-678-4800
Mailing Address - Fax:856-678-3630
Practice Address - Street 1:48 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1754
Practice Address - Country:US
Practice Address - Phone:856-678-4800
Practice Address - Fax:856-678-3630
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00420900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ482523OtherAETNA
NJ2244616000OtherAMERIHEALTH
NJ65065OtherOPERATING ENGINEERS 825
NJ223485583OtherTAX ID
NJ180031090OtherPALMETTO GBA
NJ223485583OtherBLUE CROSS
NJ180031090OtherPALMETTO GBA
NJT95309Medicare UPIN
NJ223485583OtherBLUE CROSS