Provider Demographics
NPI:1215085576
Name:COOPER, DOUGLAS M (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 ULUMALU RD.
Mailing Address - Street 2:
Mailing Address - City:HAIKU
Mailing Address - State:HI
Mailing Address - Zip Code:96708
Mailing Address - Country:US
Mailing Address - Phone:808-258-1965
Mailing Address - Fax:808-984-2155
Practice Address - Street 1:121 MAHALANI ST.
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-984-2150
Practice Address - Fax:808-984-2155
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-21082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00000123OtherALOHA CARE PROVIDER#
HI035529Medicaid
HID43556Medicare UPIN
HI54682Medicare ID - Type UnspecifiedMEDICARE PROVIDER#