1801130794 NPI number — BRIAN DAVID COOPER CMT/LMT

Table of content: BRIAN DAVID COOPER CMT/LMT (NPI 1801130794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801130794 NPI number — BRIAN DAVID COOPER CMT/LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
BRIAN
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CMT/LMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801130794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9272 CALADIUM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20110-6083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-800-5194
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7450 HERITAGE VILLAGE PLZ
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20155-3090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-800-5194
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172M00000X , with the licence number:  0019009629 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 172M00000X , with the licence number: MT1634 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)