Provider Demographics
NPI:1821780891
Name:COPPOLETTI, SAM MICHAEL
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:MICHAEL
Last Name:COPPOLETTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-2682
Mailing Address - Country:US
Mailing Address - Phone:513-356-1459
Mailing Address - Fax:
Practice Address - Street 1:1157 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-2682
Practice Address - Country:US
Practice Address - Phone:513-356-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT009752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist