Healthcare Provider Details

I. General information

NPI: 1124007125
Provider Name (Legal Business Name): GREGORY W COPPOLA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 PEACH ST
ERIE PA
16509-2419
US

IV. Provider business mailing address

1 LECOM PL
ERIE PA
16505-2571
US

V. Phone/Fax

Practice location:
  • Phone: 814-866-8610
  • Fax: 814-866-8614
Mailing address:
  • Phone:
  • Fax: 814-868-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOS010713L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS010713L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: