Provider Demographics
NPI:1699898601
Name:COOPER, JUSTIN M (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:COOPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 54TH AVE E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2724
Mailing Address - Country:US
Mailing Address - Phone:253-459-7500
Mailing Address - Fax:
Practice Address - Street 1:502 54TH AVE E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-2724
Practice Address - Country:US
Practice Address - Phone:253-459-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019083208100000X
WAOP60075152208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation