Provider Demographics
NPI:1588094130
Name:COOPER, SHARRELL (MD)
Entity type:Individual
Prefix:DR
First Name:SHARRELL
Middle Name:
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 1:120 CYPRESS EDGE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-8453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 CYPRESS EDGE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8453
Practice Address - Country:US
Practice Address - Phone:757-955-4035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 117633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine