Provider Demographics
NPI:1992570899
Name:COOPER, OWEN
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 MEMORIAL DR SE APT 629
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1751
Mailing Address - Country:US
Mailing Address - Phone:678-276-5554
Mailing Address - Fax:
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1059
Practice Address - Country:US
Practice Address - Phone:678-276-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program