Provider Demographics
NPI:1821000464
Name:COPPOLA, THERESA CROCKER (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:CROCKER
Last Name:COPPOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 PETER JEFFERSON PKWY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8844
Mailing Address - Country:US
Mailing Address - Phone:434-293-3890
Mailing Address - Fax:804-888-9567
Practice Address - Street 1:650 PETER JEFFERSON PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8844
Practice Address - Country:US
Practice Address - Phone:434-293-3890
Practice Address - Fax:804-888-9567
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA306350OtherSOUTHERN HEALTH
VA183570OtherANTHEM BCBS
VA010171181Medicaid
VA306350OtherSOUTHERN HEALTH
VA010171181Medicaid