Provider Demographics
NPI:1962580126
Name:COPPOLA, ALFONSE (PT)
Entity type:Individual
Prefix:
First Name:ALFONSE
Middle Name:
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 JOHN STREET
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702
Mailing Address - Country:US
Mailing Address - Phone:631-669-0333
Mailing Address - Fax:631-669-2436
Practice Address - Street 1:51 JOHN STREET
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702
Practice Address - Country:US
Practice Address - Phone:631-669-0333
Practice Address - Fax:631-669-2436
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ54432Medicare PIN
Q54432Medicare ID - Type Unspecified