Provider Demographics
NPI:1306807938
Name:COOPER, ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
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:PO BOX 36
Mailing Address - Street 2:ST MICHAEL INFECTIOUS DISEASE
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-0036
Mailing Address - Country:US
Mailing Address - Phone:973-877-2586
Mailing Address - Fax:973-877-2661
Practice Address - Street 1:268 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:ST MICHAEL INFECTIOUS DISEASE
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2011
Practice Address - Country:US
Practice Address - Phone:973-877-2586
Practice Address - Fax:973-877-2661
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA35197174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2048604Medicaid
NJ2048604Medicaid
NJF13873Medicare UPIN