Provider Demographics
NPI:1043790207
Name:COOPER, DYLAN M (MD, PHARMD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:M
Last Name:COOPER
Suffix:
Gender:M
Credentials:MD, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH STREET BI W2144
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912
Mailing Address - Country:US
Mailing Address - Phone:706-721-0180
Mailing Address - Fax:706-446-0077
Practice Address - Street 1:1120 15TH STREET BI W2144
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-0180
Practice Address - Fax:706-446-0077
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC377231835P0018X
GA16459207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist