Provider Demographics
NPI:1386050524
Name:COOPER, KIMBERLY ANN (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:COOPER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 DUPONT CIRCLE SUITE A
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-2770
Mailing Address - Country:US
Mailing Address - Phone:513-576-7700
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:1640 FLOSSIE DR
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:IN
Practice Address - Zip Code:47025-8424
Practice Address - Country:US
Practice Address - Phone:877-670-7264
Practice Address - Fax:812-539-1824
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34012820208000000X
LA390200000X
IN01087306A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2367501Medicaid
OH0226978Medicaid