Provider Demographics
NPI:1710179932
Name:COPPEDGE, JOHN CASEY (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CASEY
Last Name:COPPEDGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2818
Mailing Address - Country:US
Mailing Address - Phone:352-796-2141
Mailing Address - Fax:
Practice Address - Street 1:86 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2818
Practice Address - Country:US
Practice Address - Phone:352-796-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-11
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4216152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6340720001Medicare NSC
FLAL110ZMedicare PIN