Provider Demographics
NPI:1942756895
Name:KOPPAR, SHARDUL (DO)
Entity type:Individual
Prefix:DR
First Name:SHARDUL
Middle Name:
Last Name:KOPPAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 OLD MOULTRIE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:904-293-0299
Mailing Address - Fax:
Practice Address - Street 1:3232 E 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7423
Practice Address - Country:US
Practice Address - Phone:850-532-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS21535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine