Provider Demographics
NPI:1194743195
Name:COOPERSON, MARSHALL (DO)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:COOPERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 JEFFERSON ST # 196
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3436
Mailing Address - Country:US
Mailing Address - Phone:707-257-1550
Mailing Address - Fax:707-257-8219
Practice Address - Street 1:3010 BEARD RD
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3442
Practice Address - Country:US
Practice Address - Phone:707-257-1550
Practice Address - Fax:707-257-8219
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A54920Medicare PIN