Provider Demographics
NPI:1427634963
Name:BLOYD, COOPER WALLACE (MD)
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:WALLACE
Last Name:BLOYD
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 1:708 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3124
Mailing Address - Country:US
Mailing Address - Phone:415-637-9508
Mailing Address - Fax:
Practice Address - Street 1:1650 LOS GAMOS DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1850
Practice Address - Country:US
Practice Address - Phone:415-444-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA183168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program