Provider Demographics
NPI:1386749182
Name:COOPER, EVERETT BRUEN JR (MD)
Entity type:Individual
Prefix:
First Name:EVERETT
Middle Name:BRUEN
Last Name:COOPER
Suffix:JR
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 1:1353 WATERSTON DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5038
Mailing Address - Country:US
Mailing Address - Phone:706-650-7619
Mailing Address - Fax:
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:706-481-6729
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043351207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine