Provider Demographics
NPI:1710938402
Name:KOPPUZHA, BEENA C (MD)
Entity Type:Individual
Prefix:DR
First Name:BEENA
Middle Name:C
Last Name:KOPPUZHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3937 S ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224-3612
Mailing Address - Country:US
Mailing Address - Phone:941-475-6568
Mailing Address - Fax:855-250-3332
Practice Address - Street 1:3937 S ACCESS RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-3612
Practice Address - Country:US
Practice Address - Phone:941-475-6568
Practice Address - Fax:855-250-3332
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0075143207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44458YMedicare PIN
FLG83289Medicare UPIN