1023078086 NPI number — DR. LARRY COOPER MD

Table of content: DR. LARRY COOPER MD (NPI 1023078086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023078086 NPI number — DR. LARRY COOPER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
LARRY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1023078086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39046-0284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-201-6210
Provider Business Mailing Address Fax Number:
601-981-7792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38930-4030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-459-1440
Provider Business Practice Location Address Fax Number:
601-981-7792
Provider Enumeration Date:
03/24/2006

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: 207Q00000X , with the licence number:  12496 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080001597 . This is a "MEDICARE ID TYPE UNSPECIFIED" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00111401 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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