Healthcare Provider Details

I. General information

NPI: 1336566744
Provider Name (Legal Business Name): GIANNINA COPPOLA-FASICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

A28 CALLE C
CAROLINA PR
00987-7102
US

IV. Provider business mailing address

1789 CARR 21 STE 302
SAN JUAN PR
00921-3337
US

V. Phone/Fax

Practice location:
  • Phone: 787-257-2040
  • Fax:
Mailing address:
  • Phone: 787-764-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number19570
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: