=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851320923
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLOTTE INTERNAL MEDICINE ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2006
-----------------------------------------------------
Last Update Date | 12/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 HARBOR BLVD STE 19
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-5038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-624-2787
-----------------------------------------------------
Fax | 941-624-3047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 HARBOR BLVD STE 19
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-5038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-624-2787
-----------------------------------------------------
Fax | 941-624-3047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GEORGE CYRIAC KOPPUZHA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-624-2787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------