Provider Demographics
NPI:1447287446
Name:COOPER, CARNELL (MD)
Entity type:Individual
Prefix:DR
First Name:CARNELL
Middle Name:
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 1:12709 TOEPPERWEIN RD STE 302
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3260
Mailing Address - Country:US
Mailing Address - Phone:210-653-9307
Mailing Address - Fax:210-653-7014
Practice Address - Street 1:12709 TOEPPERWEIN RD STE 302
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233
Practice Address - Country:US
Practice Address - Phone:210-653-9307
Practice Address - Fax:210-653-7014
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD40386208600000X, 2086S0102X
TXS13762086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD071441100Medicaid
MDE66233Medicare UPIN