Provider Demographics
NPI:1235635137
Name:COOPER, KEVIN (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
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 1:3801 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1005
Mailing Address - Country:US
Mailing Address - Phone:847-318-9340
Mailing Address - Fax:
Practice Address - Street 1:3801 SPRING STREET
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405
Practice Address - Country:US
Practice Address - Phone:262-687-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75818-21207R00000X
IL125.072794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine