Healthcare Provider Details

I. General information

NPI: 1679556757
Provider Name (Legal Business Name): GEORGE E KOPIDAKIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 LEE BLVD SUITE 1100
LEHIGH ACRES FL
33936-4893
US

IV. Provider business mailing address

1530 LEE BLVD SUITE 1100
LEHIGH ACRES FL
33936-4893
US

V. Phone/Fax

Practice location:
  • Phone: 239-368-0241
  • Fax:
Mailing address:
  • Phone: 239-368-0241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME74612
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMA05921000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: