MEDICARE: DR. ELIZABETH COPPOLA WIKMAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4746	MA

General Provider Information

NPI Number	:	1174812390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH COPPOLA WIKMAN O.D.

Provider Business Mailing Address
First Line	:	188 BROADWAY
Second Line	:
City	:	METHUEN
State	:	MA
Zip	:	01844-3862
Country	:	US
Telephone Number	:	978-794-1445
Fax Number	:	978-975-5430

Provider Business Practice Location Address
First Line	:	39 GREEN ST
Second Line	:
City	:	NEWBURYPORT
State	:	MA
Zip	:	01950-2652
Country	:	US
Telephone Number	:	978-465-8761
Fax Number	:	978-465-6228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2011
Last Update Date	:	03/29/2011

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