Basic Information
Provider Information
NPI: 1003803909
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COPPOLA
FirstName: CHRISTOPHER
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1485 37TH ST
Address2: SUITE #102
City: VERO BEACH
State: FL
PostalCode: 329606500
CountryCode: US
TelephoneNumber: 7725674336
FaxNumber: 7725674340
Practice Location
Address1: 1485 37TH ST
Address2: SUITE #102
City: VERO BEACH
State: FL
PostalCode: 329606500
CountryCode: US
TelephoneNumber: 7725674336
FaxNumber: 7725674340
Other Information
ProviderEnumerationDate: 10/05/2005
LastUpdateDate: 12/21/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/21/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XOS7719FLY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
26788020005FL MEDICAID


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