MEDICARE: LOREN D COOPER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD00015204	WA

General Provider Information

NPI Number	:	1649267196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOREN D COOPER M.D.

Provider Business Mailing Address
First Line	:	1800 COOKS HILL RD
Second Line	:	SUITE B
City	:	CENTRALIA
State	:	WA
Zip	:	98531-9072
Country	:	US
Telephone Number	:	360-330-8591
Fax Number	:	360-330-8595

Provider Business Practice Location Address
First Line	:	1800 COOKS HILL RD
Second Line	:	SUITE B
City	:	CENTRALIA
State	:	WA
Zip	:	98531-9072
Country	:	US
Telephone Number	:	360-330-8591
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	08/04/2015

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