Provider Demographics
NPI:1578587705
Name:SCOPPETTA, DANIEL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:SCOPPETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06011-2828
Mailing Address - Country:US
Mailing Address - Phone:860-585-3906
Mailing Address - Fax:860-585-3907
Practice Address - Street 1:25 NEWELL RD
Practice Address - Street 2:SUITE D28
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5100
Practice Address - Country:US
Practice Address - Phone:860-582-1220
Practice Address - Fax:860-582-6255
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020591208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001205913Medicaid
CT020000445Medicare ID - Type Unspecified
CT001205913Medicaid