Basic Information
| Provider Information | |||||||||
| NPI: | 1598763997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COPPOLA | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386364 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 DURHAM RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MADISON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064432674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032458035 | ||||||||
| FaxNumber: | 2032454315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2005 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 015953 | CT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VE0102X | 015953 | CT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 001159532 | 05 | CT | MEDICAID |