Provider Demographics
NPI:1164449690
Name:COPPEDGE, JOHN HILL JR (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HILL
Last Name:COPPEDGE
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:86 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601
Mailing Address - Country:US
Mailing Address - Phone:352-796-2141
Mailing Address - Fax:352-796-2325
Practice Address - Street 1:86 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601
Practice Address - Country:US
Practice Address - Phone:352-796-2141
Practice Address - Fax:352-796-2325
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC000914152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035728600Medicaid
FL035728600Medicaid
T93808Medicare UPIN
FL6340720001Medicare NSC