Provider Demographics
NPI:1962427351
Name:COOPER, MARK C (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:COOPER
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND59432085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND142005OtherUCARE#
ND2400032OtherMEDICA #
MN4F531COOtherMNBS #
ND2400078OtherMEDICA #
ND676557OtherAMERICA'S PPO/ARAZ #
ND10269OtherNDBS #
MN2F531COOtherMNBS #
NDND200010OtherLHS #
NDHP25729OtherHEALTHPARTNERS #
ND16443Medicaid
ND276202100Medicaid
ND28131COOtherMNBS #
ND34Q70COOtherMNBS #
NDDA9011015524OtherPREFERRED ONE #
NDDA9011015524OtherPREFERRED ONE #
ND142005OtherUCARE#
MN4F531COOtherMNBS #
ND2400078OtherMEDICA #
MN929000010Medicare ID - Type UnspecifiedMN MEDICARE #
ND16443Medicaid