Provider Demographics
NPI:1194729525
Name:COOPER, ROBERT WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:COOPER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-0247
Mailing Address - Country:US
Mailing Address - Phone:606-549-2933
Mailing Address - Fax:606-549-3036
Practice Address - Street 1:475 N HIGHWAY 25 W # WN
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1576
Practice Address - Country:US
Practice Address - Phone:606-549-2933
Practice Address - Fax:606-549-3036
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2025-03-12
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
KY18598207Q00000X
TN53545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201533510Medicaid
MO135570021OtherMEDICARE PTAN
MO3518OtherBLUE CROSS/BLUE SHIELD
MOP00792573OtherRAIL ROAD MEDICARE
TNQ020836Medicaid
MO115556OtherHEALTHLINK
KY7100398340Medicaid
TNQ020836Medicaid
MO201533510Medicaid
TN1030812011Medicare PIN
MO000015278Medicare PIN