Provider Demographics
NPI:1629070941
Name:COPPOTELLI, BERT ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:ANTHONY
Last Name:COPPOTELLI
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 1:2 LEE RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351-3015
Mailing Address - Country:US
Mailing Address - Phone:860-376-4451
Mailing Address - Fax:860-376-5977
Practice Address - Street 1:2 LEE RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:CT
Practice Address - Zip Code:06351-3015
Practice Address - Country:US
Practice Address - Phone:860-376-4451
Practice Address - Fax:860-376-5977
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT26684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010621809OtherTID#
010621809OtherUNHC
2V1389OtherHEALTHNET
00126684004OtherBCBS
CT001266840Medicaid
010621809OtherCIGNA
010621809OtherTID#
00126684004OtherBCBS