1629017199 NPI number — JAMIE L COOPER DO

Table of content: JONATHAN DU (NPI 1407433352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629017199 NPI number — JAMIE L COOPER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
JAMIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1629017199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8051 S EMERSON AVE STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46237-8633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-865-3600
Provider Business Mailing Address Fax Number:
317-885-3850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 HADLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46158-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-584-3454
Provider Business Practice Location Address Fax Number:
317-584-3435
Provider Enumeration Date:
06/06/2006

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: 207V00000X , with the licence number:  02002828A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000720579 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7554169 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000480530 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200543500 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1935002 . This is a "CIGNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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