Provider Demographics
NPI:1871562975
Name:COOPER, JEFFREY C (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
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 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-243-4450
Mailing Address - Fax:574-243-4405
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-243-4450
Practice Address - Fax:574-243-4405
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043721A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200038580Medicaid
IN000000110542OtherANTHEM PROVIDER NUMBER
IN200038580Medicaid
IN146470032Medicare PIN
IN340013018Medicare PIN