Provider Demographics
NPI:1790724052
Name:COPPOLA, MICHAEL PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
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 1:801 CROMWELL PARK DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2539
Mailing Address - Country:US
Mailing Address - Phone:410-590-0443
Mailing Address - Fax:410-590-4403
Practice Address - Street 1:801 CROMWELL PARK DR
Practice Address - Street 2:SUITE 108
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2539
Practice Address - Country:US
Practice Address - Phone:410-590-0443
Practice Address - Fax:410-590-4403
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD74925207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6193374Medicaid
MA054100OtherTUFTS HEALTH PLAN
MA11550OtherHEALTH NEW ENGLAND
MAJ04196OtherBLUE CROSS BLUE SHIELD
MAJ04196OtherBLUE CROSS BLUE SHIELD
MAJ04196Medicare ID - Type Unspecified