Provider Demographics
NPI:1679651905
Name:COPPOLA, ANTHONY J (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:COPPOLA
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 1:111 GOOSE LN
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-5101
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:860-444-4752
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:860-444-4752
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025067207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4041679Medicaid
CT930125667Medicare UPIN
CT4041679Medicaid
E57593Medicare UPIN
CT110008783Medicare ID - Type Unspecified