Provider Demographics
NPI:1366599938
Name:COOPERMAN, OLIVER BURTON (MD)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:BURTON
Last Name:COOPERMAN
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 1:2155 W STATE ROUTE 89A
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-5468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:928-282-2560
Practice Address - Street 1:2155 W STATE ROUTE 89A
Practice Address - Street 2:SUITE 203
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5468
Practice Address - Country:US
Practice Address - Phone:928-282-1233
Practice Address - Fax:928-282-2560
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT74572084P0800X, 2084P0802X, 2084P0804X
WY4157A2084P0800X, 2084P0802X, 2084P0804X, 2084P0804X
AZ368692084P0800X, 2084P0802X, 2084P0804X
CAG228952084P0800X, 2084P0802X, 2084P0804X, 2084P0804X
IDM110892084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0086445Medicaid
AZ211925Medicaid
AZ211925Medicaid