Provider Demographics
NPI:1154593846
Name:ALAN R COOPER DPM
Entity type:Organization
Organization Name:ALAN R COOPER DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-279-0363
Mailing Address - Street 1:4569A LANSMORE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3352
Mailing Address - Country:US
Mailing Address - Phone:937-279-0363
Mailing Address - Fax:937-276-2028
Practice Address - Street 1:4569A LANSMORE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3352
Practice Address - Country:US
Practice Address - Phone:937-279-0363
Practice Address - Fax:937-276-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1527213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0380976Medicaid
OH0380976Medicaid
OH9262191Medicare PIN
OH0367670001Medicare NSC