Provider Demographics
NPI:1578998126
Name:ANGELO COPPOLA, MD, PSC
Entity Type:Organization
Organization Name:ANGELO COPPOLA, MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-257-2040
Mailing Address - Street 1:A28 CALLE C
Mailing Address - Street 2:JARDINES DE CAROLINA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-7102
Mailing Address - Country:US
Mailing Address - Phone:787-257-2040
Mailing Address - Fax:787-750-4126
Practice Address - Street 1:A28 CALLE C
Practice Address - Street 2:JARDINES DE CAROLINA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987-7102
Practice Address - Country:US
Practice Address - Phone:787-257-2040
Practice Address - Fax:787-750-4126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8825174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD08568Medicare UPIN