Provider Demographics
NPI:1982648101
Name:KOPPUZHA, GEORGE C (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:C
Last Name:KOPPUZHA
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 1:2091 TAMIAMI TRL
Mailing Address - Street 2:STE B
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-2112
Mailing Address - Country:US
Mailing Address - Phone:941-624-2787
Mailing Address - Fax:855-211-3727
Practice Address - Street 1:2091 TAMIAMI TRL
Practice Address - Street 2:STE B
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2112
Practice Address - Country:US
Practice Address - Phone:941-625-9494
Practice Address - Fax:941-743-8562
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0074583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255240000Medicaid
FL44529OtherBLUE CROSS & BLUE SHIELD
279368OtherWELLCARE
FLAK532OtherMEDICARE GROUP
FL44529OtherBLUE CROSS & BLUE SHIELD
FLAK532OtherMEDICARE GROUP