1730274457 NPI number — DR. JACK MEDFORD COOPER MD

Table of content: DR. JACK MEDFORD COOPER MD (NPI 1730274457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730274457 NPI number — DR. JACK MEDFORD COOPER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
JACK
Provider Middle Name:
MEDFORD
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:
1730274457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
634 UPTOWN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR HILL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75104-3529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-637-1300
Provider Business Mailing Address Fax Number:
866-353-7586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
634 UPTOWN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR HILL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75104-3529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-637-1300
Provider Business Practice Location Address Fax Number:
866-353-7586
Provider Enumeration Date:
10/04/2006

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: 207W00000X , with the licence number:  F2614 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 751622524 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 86770X . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0612336 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0612336 . This is a "AETNA POS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0016DQ . This is a "BCBS GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 112288904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112288905 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2314758 . This is a "BCBS BLUE LINK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 180011221 . This is a "MEDICARE RR DALLAS COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 180032049 . This is a "MEDICARE RR ELLIS COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4237247 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".




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