Provider Demographics
NPI:1609962182
Name:STACEY, COOPER BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:COOPER
Middle Name:BRIAN
Last Name:STACEY
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 1:51 LYNDON ST
Mailing Address - Street 2:#1
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301
Mailing Address - Country:US
Mailing Address - Phone:603-228-9977
Mailing Address - Fax:
Practice Address - Street 1:253 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301
Practice Address - Country:US
Practice Address - Phone:603-229-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30201740Medicaid
NHG87681Medicare UPIN
NHRE6434Medicare ID - Type Unspecified