Provider Demographics
NPI:1306945217
Name:COOPER, ANNIE MISSA (MD,)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:MISSA
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 COLLIER RD NW
Mailing Address - Street 2:SUITE M-215
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1613
Mailing Address - Country:US
Mailing Address - Phone:404-355-2914
Mailing Address - Fax:404-355-2917
Practice Address - Street 1:35 COLLIER RD NW
Practice Address - Street 2:SUITE M-215
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1613
Practice Address - Country:US
Practice Address - Phone:404-355-2914
Practice Address - Fax:404-355-2917
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA41418174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41418OtherSTATE MEDICAL LICENSE
GABC5134832OtherDEA
GA41418OtherSTATE MEDICAL LICENSE
GA26BDGQMMedicare ID - Type Unspecified