Provider Demographics
NPI:1497923122
Name:COPPEDGE AND WOOSTER PA
Entity Type:Organization
Organization Name:COPPEDGE AND WOOSTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HILL
Authorized Official - Last Name:COPPEDGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:352-796-2141
Mailing Address - Street 1:86 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2818
Mailing Address - Country:US
Mailing Address - Phone:352-796-2141
Mailing Address - Fax:352-796-2325
Practice Address - Street 1:86 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2818
Practice Address - Country:US
Practice Address - Phone:352-796-2141
Practice Address - Fax:352-796-2325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0499280001Medicare NSC