Provider Demographics
NPI:1710045869
Name:COPPOLA, VINCENT (DPM)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 WASHINGTON AVE
Mailing Address - Street 2:STE A
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1956
Mailing Address - Country:US
Mailing Address - Phone:973-667-3412
Mailing Address - Fax:973-667-3524
Practice Address - Street 1:591 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110
Practice Address - Country:US
Practice Address - Phone:973-667-3412
Practice Address - Fax:973-667-3524
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00235700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU62784Medicare ID - Type Unspecified
U62784Medicare UPIN