MEDICARE: DR. GEORGE CYRIAC KOPPUZHA MD

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	207R00000X	Internal Medicine Physician	ME74583	FL
2	207R00000X	Internal Medicine Physician	ME0074583	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	AK532	OTHER	FL	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	44529	OTHER	FL	BLUE CROSS & BLUE SHIELD
3	279368	OTHER		WELLCARE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982648101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE CYRIAC KOPPUZHA MD

Provider Business Mailing Address
First Line	:	2400 HARBOR BLVD
Second Line	:	SUITE 19
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5038
Country	:	US
Telephone Number	:	941-624-2787
Fax Number	:	941-624-3047

Provider Business Practice Location Address
First Line	:	2400 HARBOR BLVD
Second Line	:	SUITE 19
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5038
Country	:	US
Telephone Number	:	941-624-2787
Fax Number	:	941-624-3047

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	12/08/2025

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